Fillable New License2019mgmt (Commonwealth of Massachusetts)

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New License2019mgmt (Commonwealth of Massachusetts)

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The New License2019mgmt (Commonwealth of Massachusetts) form is 19 pages long and contains:

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  • 71 check-boxes
  • 453 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Street Address
Entity Name
2. BUSINESS ENTITY INFORMATION
FEIN
DBA
Municipality
APPLICATION FOR A NEW LICENSE
Manager of Record
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.
1. LICENSE CLASSIFICATION INFORMATION
TYPE CATEGORYON/OFF-PREMISES CLASS
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.
3. DESCRIPTION OF PREMISES
Occupancy Number:
Seating Capacity:
Number of Entrances:Total Square Footage:
Number of Exits:Number of Floors
Is this license application pursuant to special legislation?
Chapter Acts of
NoYes
Phone
Alternative Phone
Email
Website
The entity that will be issued the license and have operational control of the premises.
Name:
Title:
Phone:
Email:
4. APPLICATION CONTACT
The application contact is the person whom the licensing authorities should contact regarding this application.
1
The Commonwealth of Massachusetts
Alcoholic Beverages Control Commission
95 Fourth Street, Suite 3, Chelsea, MA 02150-2358
www.mass.gov/abcc
APPLICATION FOR A NEW LICENSE
State of Incorporation
Is the Corporation publicly traded?
5. CORPORATE STRUCTURE
NoYes
Entity Legal Structure
Date of Incorporation
6. PROPOSED OFFICERS, STOCK OR OWNERSHIP INTEREST
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.
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
NoYes
Additional pages attached?
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
Title and or Position
NoYes
Percentage of Ownership US Citizen MA Resident
NoYes
Director/ LLC Manager
NoYes
APPLICATION FOR A NEW LICENSE
6B. PREVIOUSLY HELD INTEREST IN AN ALCOHOLIC BEVERAGES LICENSE
Has any individual or entity 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
6C. DISCLOSURE OF LICENSE DISCIPLINARY ACTION
Have any of the disclosed licenses listed in question 6Aor 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
Name License Type License Name Municipality
7. OCCUPANCY OF PREMISES
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 will occupy the premises
Please complete all fields in this section. Please provide proof of legal occupancy of the premises.
• If the applicant entity owns the premises, a deed is required.
• If leasing or renting the premises, a signed copy of the lease is required.
• If the lease is contingent on the approval of this license, and a signed lease is not available, a copy of the unsigned lease and a letter
of intent to lease, signed by the applicant and the landlord, is required.
• If the real estate and business are owned by the same individuals listed in question 6, either individually or through separate
business entities, a signed copy of a lease between the two entities is required.
Landlord Email
6A. INTEREST IN AN ALCOHOLIC BEVERAGES LICENSE
Name License Type License Name Municipality
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
3
APPLICATION FOR A NEW LICENSE
A. Purchase Price for Real Estate
B. Purchase Price for Business Assets
C. Other * (Please specify below)
8. FINANCIAL DISCLOSURE
D. Total Cost
Name of Contributor Amount of Contribution
Total:
Name of Lender Amount Type of Financing
Is the lender a licensee pursuant
to M.G.L. Ch. 138.
Provide a detailed explanation of the form(s) and source(s) of funding for the cost identified above.
9. PLEDGE INFORMATION
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.
Are you seeking approval for a pledge?
Yes No
To whom is the pledge being made?
License Stock Inventory
Please indicate what you are seeking to pledge (check all that apply)
Please provide signed pledge documentation.
SOURCE OF CASH CONTRIBUTION
SOURCE OF FINANCING
FINANCIAL INFORMATION
4
*Other Cost(s): (i.e. 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):”
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.
10. MANAGER APPLICATION
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.
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.
Date of Action Name of License State City Reason for suspension, revocation or cancellation
I hereby swear under the pains and penalties of perjury that the information I have provided in this application is true and accurate:
Manager's Signature
Date
A. MANAGER INFORMATION
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
Date Municipality Charge Disposition
Yes No
*Manager must be a U.S. Citizen
5
Residential Address
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11. MANAGEMENT AGREEMENT
NoYes
Are you requesting approval to utilize a management company through a management agreement?
If yes, please fill out section 11.
11A. 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
11B. EXISTING MANAGEMENT AGREEMENTS AND INTEREST IN AN ALCOHOLIC BEVERAGES
LICENSE
Does any individual or entity identified in question 11A, 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.
Please provide a narrative overview of the Management Agreement. Attach additional pages, if necessary.
6
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.
11C. PREVIOUSLY HELD INTEREST IN AN ALCOHOLIC BEVERAGES LICENSE
Has any individual or entity identified in question 11A, 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
Name License Type License Name Municipality
If yes, list in table below. Attach additional pages, if necessary, utilizing the table format below.
11D. PREVIOUSLY HELD MANAGEMENT AGREEMENT
Has any individual or entity identified in question 11A, 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.
11E. DISCLOSURE OF LICENSE DISCIPLINARY ACTION
Has any of the disclosed licenses listed in questions in section 11B, 11C, 11D 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
11F. 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:
Signature:
Date:
Title:
ABCC Licensee Officer/LLC Manager
Management Agreement Entity Officer/LLC Manager
7
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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.
Signature: Date:
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.
Title:
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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
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
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)
__________________________
NEW LICENSE
To apply for an alcoholic beverages retail license, you will need the following:
• New Retail 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
• CORI Authorization Form Complete one for each individual with financial or beneficial
interest in the entity that is applying AND one for the proposed manager of
record. This form must be notarized with a stamp or raised seal.
• Manager Application
• Proof of Citizenship for the proposed Manager of Record.
• Vote of the Corporate Board
• Supporting Financial Records for all financing and or loans, including pledge
documents, if applicable.
• Legal Right to Occupy, a lease or deed.
• Floor Plan
• Abutter's Notification
• Advertisement
• Monetary Transmittal Form
• $200 Fee paid online through our online payment link:
• Payment Receipt
• Additional information, if necessary, utilizing the formats provided and or any
affidavits.
• Management Agreement, if applicable, requires the following:
Please Note: You may be requested to submit additional supporting documentation if
necessary.
ABCC PAYMENT WEBSITE
• Management Agreement Application
• Management Agreement
• Vote of the Entity
• CORI Forms for all listed in Section 11 and attachments
6. PROPOSED OFFICERS, STOCK OR OWNERSHIP INTEREST (Continued...)
ADDENDUM A
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.).
Entity Name
Percentage of Ownership in Entity being Licensed
(Write "NA" if this is the entity being licensed)
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/ 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
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 A NEW LICENSE
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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Completed 27 July 2020

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