Worcester Liquor License by PermitDocsPrivate

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									                                City of Worcester, Massachusetts
          Michael V. O’Brien                                                  Timothy J. McGourthy
            City Manager                                                    Chief Development Officer
                                                                    Executive Office of Economic Development


                                                                                  Joel J. Fontane
                                                                                     Director
                                                                      Planning & Regulatory Services Division


   LIQUOR LICENSE APPLICATION CHECKLIST

Instructions:

   1. Fill out the attached application completely (please type or print; illegible
      applications will be returned).

   2. Check Zone for availability with Division of Planning & Regulatory Services, (508)
      799-1400 ext 260.

   3. Obtain a List of Abutters (obtained at the Assessor’s Office). It is the applicant’s
      responsibility to notify abutters within three (3) days after the advertisement
      appears by certified mail return receipt.

   4. Obtain a Right of Entry/Purchase Sale Agreement, Copy of Lease or Notice from
      landlord. It is required that there must be a statement from the landlord giving
      permission for liquor to be on the premises.

   5. Provide proof of Sole Proprietorship (if one owner of entire business).

   6. Provide proof of Partnership (if a contract entered into by two or more persons
      where each agrees to furnish part of the capital and labor for a business
      enterprise, and by which each shares in some fixed proportion in profit and
      losses).

   7. Provide proof of Corporation or LLC (if a body of persons granted a charter
      legally recognizing it as a separate entity having its own rights and privileges and
      liabilities distinct from those of its members).

   8. Provide a plan of the premises. If there will be alcohol stored in basement or
      alcohol served outside, that must be shown on plan.

   9. Provide a Business Plan (how the business will be managed).

   10. Provide a recent Certificate of Good Standing (for an established corporation).
       This can be obtained from Department of Revenue, 1-800-392-6089.


                            License Commission, Planning & Regulatory Services Division
         455 Main Street Room 404, Worcester, MA 01608 Phone: (508) 799-1400 ext. 234, Fax: (508) 799-1406
                                             license@worcesterma.gov
   11. Provide documentation of all sources of financing (loan papers, checking
       accounts, stock sales, etc.). Applicant must provide copies of where the financing
       comes from.

   12. Complete the Personal Information Sheet and CORI for any person who will have
       an ownership in the business.

   13. Provide a copy of the manager’s birth certificate, passport or Certificate of
       Naturalization.

   14. Complete Form C (attached) financing form.

   15. Obtain a Business Certificate (may be obtained in the City Clerk’s Office, Room
       206, City Hall).

   16. If a restaurant, submit a copy of the proposed menu.

   17. If this is a license transfer application, a copy of the Purchase and Sale
       Agreement must be provided.

   18. Submit original completed application plus six (6) copies; no staples.

   19. Filing fees: after application is processed, you will be billed $50.00 for the Liquor
       Application Filing and $50.00 for the Liquor Advertising Fee. If filing on the
       deadline date, the application must be filed by 2:00 PM.

   20. At the time of your hearing, you will need to bring a check for $200.00 payable to
       the A.B.C.C. and proof of Notice to Abutters (certified green return receipt cards).

Applications will NOT be accepted without all required paperwork.




                            License Commission, Planning & Regulatory Services Division
         455 Main Street Room 404, Worcester, MA 01608 Phone: (508) 799-1400 ext. 234, Fax: (508) 799-1406
                                             license@worcesterma.gov
                                        Commonwealth of Massachusetts
                                            Department of the State Treasurer
                                         Alcoholic Beverages Control Commission
                                                   239 Causeway Street
                                                    Boston, MA 02114
                                               Telephone: (617) 727-3040
                                                   Fax: (617) 727-1258

   Timothy P. Cahill                                                                                Kim S. Gainsboro
Treasurer and Receiver General                                                                            Chairman



                     ALCOHOLIC BEVERAGES CONTROL COMMISSION ADVISORY
                          MANDATORY LIQUOR LIABILITY INSURANCE



                      On May 28, 2010 the legislature amended M.G.L. c. 138, §12 by requiring existing
            licensees and applicants for alcoholic beverages licenses issued under M.G.L. c. 138, §12, to have a
            MINIMUM AMOUNT OF MANDATORY LIQUOR LIABILITY INSURANCE
            COVERAGE. Effective August 26, 2010, no license under M.G.L. c. 138, §12 shall be issued or
            renewed until the applicant or licensee provides proof of mandatory insurance coverage by filing a
            certificate of insurance in a form acceptable to the local licensing authority (“LLA”). As a result,
            applicants for §12 licenses must provide proof of insurance coverage under a liquor legal liability
            insurance policy for bodily injury or death for a minimum amount of $250,000 on account of injury
            to or death of 1 person, and $500,000 on account of any 1 accident resulting in injury to or death of
            more than 1 person as a condition to receive a license. Existing §12 licensees, which include any
            entities wishing to transfer a license, must provide proof of insurance coverage under a liquor legal
            liability insurance policy for bodily injury or death for a minimum amount of $250,000 on account
            of injury to or death of 1 person, and $500,000 on account of any 1 accident resulting in injury to
            or death of more than 1 person as a condition to renew a license.

                    Although LLA’s retain the discretion to set the amount of insurance coverage required
            pursuant to M.G.L. c. 138, §64A for §12 licensees that are repeat offenders in selling or serving
            alcoholic beverages to under-age or intoxicated individuals, they DO NOT have the discretion to
            increase the minimum amount of insurance coverage required by this new law. Moreover, LLA’s
            should be aware that licensees have the ability to appeal an action of the LLA in requiring
            insurance pursuant to M.G.L. c. 138, §64A and that after hearing, the ABCC, retains the discretion
            to modify this amount pursuant to M.G.L. c. 138, § 67.

                    As a result of this amendment, the ABCC will be revising the renewal applications for
            calendar year 2011 to ensure compliance with this new LIQUOR LIABILITY INSURANCE law.
            Individuals with questions concerning this Advisory may contact the ABCC at 617-727-3040 x 31.

            (Issued July 27, 2010)
                           NOTICE



EFFECTIVE NOVEMBER 15, 2004, AS REQUIRED BY CHAPTER 304 OF THE
ACTS OF 2004, AN ACT RELATIVE TO FIRE SAFETY IN THE
COMMONWEALTH, EVERY LICENSE HOLDER UNDER M.G.L. C. 138 SEC
12 MUST SUBMIT AS A CONDITION OF A LICENSE A VALID CERTIFICATE
OF INSPECTION ISSUED BY A LOCAL INSPECTOR AND SIGNED BY THE
HEAD OF THE FIRE DEPARTMENT FOR THE CITY, TOWN, OR DISTRICT
IN WHICH THE PREMISES IS LOCATED.
                           Application for Retail Alcoholic Beverage License

                                        City/Town          Worcester, MA

1. Transaction:

     New License                 New Officer/Director                Transfer of Stock                 Issuance of Stock

     Transfer of License         New Stockholder                     Management/Operating Agreement


The following transactions must be processed as new licenses:
   Seasonal to Annual            6-Day to 7-Day License        Wine & Malt to All Alcohol

IMPORTANT ATTACHMENTS: The applicant must attach a vote of the entity authorizing all requested
transactions, including the appointment of a Manager of Record or principal representative.

2. Type of License:

     §12 Restaurant            §12 Hotel                  §12 Club                       §12 Veterans Club

     §12 General On-Premise          §12 Tavern (No Sundays)         §15 Package Store


3. License Catagory:

     All Alcoholic Beverages                  Wine & Malt Beverages Only                     Wine or Malt Only

     Wine & Malt Beverages with Cordials/Liqueurs Permit


4. License Class:

     Annual                                   Seasonal


5. Contact Person concerning this application (attorney if applicable)

  NAME:

  ADDRESS:

  CITY/TOWN:                                                    STATE                         ZIP CODE

  CONTACT PHONE NUMBER:                                               FAX NUMBER:

  EMAIL:
6. Licensee Information:

Legal Name/Entity of Applicant:(e.g Corporation, LLC, Individual)

Business Name (if different) :                                                    Manager of Record:

ABCC License Number (for existing licenses only) :

Address of Licensed Premises:                                           CITY/TOWN:                               STATE               ZIP

Business Phone:                                                     Cell Phone:

Email:                                                     Website:


7. Description of Premises:
Please provide a complete description of the premises to be licensed. The description should include the location of all entrances
and exits.




  IMPORTANT ATTACHMENTS: The applicant must attach a floor plan with dimensions and square footage for each floor & room.


Occupancy Number:                                                              Seating Capacity:

8. Occupancy of Premises:

By what right does the applicant have possession and/or legal occupancy of the premises?                       Please Select

IMPORTANT ATTACHMENTS: The applicant must submit a copy of the final lease or documents evidencing a
legal right to occupy the premises.                                                                            Other:

Landlord is a(n):      Please Select                            Other

Name                                                                         Phone:

Address:                                                      City/Town:                               State                   Zip

Initial Lease Term: Beginning Date                                                Ending Date

Renewal Term:                                                 Options/Extensions at                            Years Each

Rent:                               per year                  Rent:                                    per month

Do the terms of the lease or other arrangement require payments to the Landlord based on a percentage of the alcohol sales?
Yes      No

IMPORTANT ATTACHMENTS: If yes, the Landlord is deemed a person or entity with a financial or beneficial interest in this license.
Each individual with an ownership interest in the Landlord must be disclosed in §10 and must submit a completed Personal
Information Form attached to this application. Entity formation documents for the Landlord entity must accompany the application to
confirm the individuals disclosed.
9. Licensee Structure:

The Applicant is a(n):      Please Select                                        Other :

If the applicant is a Corporation or LLC, complete the following:

State of Incorporation/Organization:                                        Date of Incorporation/Organization:


Is the Corporation publicly traded? Yes             No



10. Interests in this License:
List all individuals involved in the entity (e.g. corporate stockholders, directors, officers and LLC members and managers) and
any person or entity with a direct or indirect, beneficial or financial interest in this license (e.g. landlord with a percentage rent
based on alcohol sales).
IMPORTANT ATTACHMENTS: All individuals or entities listed below are required to complete a Personal Information Form.

            Name                            Title                     Stock or % Owned                     Other Beneficial Interest




*If additional space is needed, please use last page.

11. Existing Interests in Other Licenses:
Does any individual listed in §10 have any direct or indirect, beneficial or financial interest in any other license to sell alcoholic
beverages? Yes         No          If yes, list said interest below:

            Name                       License Type                                        Licensee Name & Address

                                Please Select

                                Please Select

                                Please Select

                                Please Select

                                Please Select

                                Please Select

                                Please Select


*If additional space is needed, please use last page.
12. Previously Held Interests in Other Licenses:
Has any individual listed in §10 who has a direct or indirect beneficial interest in this license ever held a direct or indirect, beneficial or
financial interest in a license to sell alcoholic beverages, which is not presently held? Yes       No       If yes, list said interest below:


                                                                                                                                       Reason
            Name                                            Licensee Name & Address                                     Date
                                                                                                                                     Terminated

                                                                                                                                  Please Select


                                                                                                                                  Please Select


                                                                                                                                  Please Select



13. Disclosure of License Disciplinary Action:
Have any of the disclosed licenses to sell alcoholic beverages listed in §11 and/or §12 ever been suspended, revoked or cancelled?
Yes    No        If yes, list said interest below:


              Date                                License                               Reason of Suspension, Revocation or Cancellation




14. Criminal Record:
Has any individual listed in §10 or who has a direct or indirect beneficial interest in this license ever been convicted of a municipal,
state, federal or military crime? Yes     No
If yes, the individual must provide an affidavit as to any and all charges as well as the disposition.




15. Citizenship and Residency Requirements for a (§15) Package Store License ONLY:
1. Are all Directors/LLC Managers U.S. Citizens?                                                          Yes      No

2. Are a majority of Directors/LLC Managers Massachusetts Residents?                                      Yes      No

3. Is the License Manager or Principal Representative a U.S. Citizen?                                     Yes      No

4. Are all members and partners involved at least twenty-one years old?                                   Yes      No


16. Citizenship and Residency Requirements for (§12) Restaurant, Hotel, Club, General On Premise, Tavern, Veterans Club
License ONLY:
1. Are all Directors/LLC Managers U.S. Citizens?                                                          Yes      No

2. Are a majority of Directors/LLC Managers Massachusetts Residents?                                      Yes      No

3. Is the License Manager or Principal Representative a U.S. Citizen?                                     Yes      No
17. Costs Associated with License Transaction:

  A. Purchase Price for Real Property:

  B. Purchase Price for Business Assets:

  C. Costs of Renovations/Construction:

  D. Initial Start-Up Costs:                                                       IMPORTANT ATTACHMENTS: Submit any and all
                                                                                   records, documents and affidavits including loan
  E. Purchase Price for Inventory:                                                 agreements that explain the source(s) of money for this
                                                                                   transaction. Sources of cash should include a minimum
  F. Other: (Specify)                                                              of three (3) months of bank statements.


  G: TOTAL COST

  H. TOTAL CASH

  I. TOTAL AMOUNT FINANCED                                                         The amounts listed in subsections (H) and (I)
                                                                                   must total the amount reflected in (G).

18. Provide a detailed explanation of the form(s) and source(s) of funding for the costs identified in §17 (include loans,
mortgages, lines of credit, notes, personal funds, gifts):




*If additional space is needed, please use last page.


19. List each lender and loan amount(s) from which "total amount financed" noted in subsections 17(I) will derive:

                    Name                                       Dollar Amount                                  Type of Financing




*If additional space is needed, please use last page.
Does any individual or entity listed in §19 as a source of financing have a direct or indirect, beneficial or financial interest in this
license or any other license(s) granted under Chapter 138? Yes          No
If yes, please describe:
20. Pledge: (i.e. collateral for a loan)
Is the applicant seeking approval to pledge the license?               Yes       No

If yes, describe terms and conditions and to whom:


If a corporation, is the applicant seeking approval to pledge any of the corporate stock?          Yes     No

If yes, to whom:                                           Number of Shares


Is the applicant pledging the inventory?     Yes     No               If yes, to whom:

IMPORTANT ATTACHMENTS: If you are applying for a pledge, submit the pledge agreement, the promissory note and a vote of
the Corporation/LLC approving the pledge.


21. Construction of Premise
Are the premises being remodeled, redecorated or constructed in any way?      If YES, please provide a description of the work being
performed on the premises:         Yes    No




                                      If all the information is not completed the
                                              application may be returned
                                            APPLICANT'S STATEMENT


I,                              the: sole proprietor;     partner;    corporate principal; LLC/LLP member
of                                     , hereby submit this application for                         (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 statement 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 does not violate any requirement of
the ABCC or other state law or local ordinances;

(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
Application information 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.

Signature:                                                             Date


Title
                                            The Commonwealth   of Massachusetts
                                          Alcoholic Beverages Control Commission
                                                    239 Causeway Street
                                                     Boston, MA 02114
                                                     www.mass.gov/abcc


                                               Personal Information Form


Each individual listed in §10 of this application must complete this form.

1. Licensee Information:

Legal Name of Licensee:                                         Business Name (d/b/a)

Address:                                                            ABCC License Number:
                                                                       (If existing licensee)
City/Town                                                   State                     Zip Code

Phone Number of Premise                                         EIN of License:


2. Personal Information:


Individual Name                                                         Home Phone Number:

Address:

City/Town                                                   State                     Zip Code

Social Security Number                                                        Date of Birth

Place of Employment

Have you ever been convicted of a state, federal or military crime? Yes                No
If yes, attach an affidavit as to all charges and disposition.

3. Financial Interest:
Provide a detailed description of your direct or indirect, beneficial or financial interest in this license.




  IMPORTANT ATTACHMENTS: For all cash contributions, attach last 3 months of bank statements for the source(s) of this cash.
  *If additional space is needed, please use the last page*

I hereby swear under the pains and penalties of perjury that the information I have provided in this application is
true and accurate:
Signature                                                                          Date

Title                                                  (If Corporation/LLC Representative)
                                                                    The Commonwealth    of Massachusetts
                                                                   Alcoholic Beverages Control Commission
                                                                             239 Causeway Street
                                                                              Boston, MA 02114
                                                                              www.mass.gov/abcc


                                                                          Manager Application

  All proposed managers are required to complete a Personal Information Form, and attach a copy of the
  corporate vote authorizing this action and appointing a manager.
  1. Licensee Information:

  Legal Name of Licensee:                                                            Business Name (d/b/a)

  Address:

  City/Town                                                                      State                    Zip Code

  ABCC License Number:                                                               Phone Number of Premise
          (If existing licensee)

  2. Manager Information:


  Name:                                                                                   Cell Phone Number:

  Are you a U.S. Citizen: Yes                                 No                         Court and Date of Naturalization:
  (Submit proof of citizenship and/or naturalization such as Voter's Certificate, Birth Certificate or Naturalization Papers)

  List the number of hours per week you will spend on the licensed premises:
  Have you ever been charged or convicted of a state, federal or military crime? Yes                                       No
  If yes, attach an affidavit as to all charges and disposition.

  Do you now, or have you ever, held any direct or indirect, beneficial or financial interest in a license to sell
  alcoholic beverages? Yes      No

  If yes, please describe:
  Have you ever been the Manager of Record of a license to sell alcoholic beverages that has been suspended,
  revoked or cancelled? Yes    No

  If yes, please describe:
  *If additional space is needed, please use the last page*

  Please list your employment for the past ten years (Dates, Position, Employer, Address and Telephone):


  *If additional space is needed, please use the last page*




I hereby swear under the pains and penalties of perjury that the information I have provided in this application is true and
accurate:

                 Signature                                                                    Date
Additional Space

Please note which question you are using this space for.
  THIS FORM TO BE FILLED OUT BY ANYONE WHO WILL HAVE
         DIRECT/INDIRECT INTEREST IN THE BUSINESS
NAME

SOCIAL SECURITY #

DRIVER’S LICENSE #

DATE OF BIRTH

ARE YOU A UNITED STATES CITIZEN?

WHERE WERE YOU BORN (CITY, STATE, COUNTRY)

IDENTIFY YOUR CRIMINAL RECORD, (MASSACHUSETTS, MILITARY, ANY OTHER STATE OR
FEDERAL COURT): ANY OTHER ARREST OR APPEARANCE IN CRIMINAL COURT CHARGED
WITH A CRIMINAL OFFENSE REGARDLESS OF FINAL DISPOSITION:
      YES                            NO         MUST CHECK EITHER YES OR NO

IF YES, PLEASE DESCRIBE OFFENSE(S) SPECIFIC CHARGE AND DISPOSITION (FINE,
PENALTY, ETC.)

HOME ADDRESS                                   TIME AT THIS ADDRESS

PREVIOUS ADDRESS                               TIME AT THIS ADDRESS

FATHER’S NAME

MOTHER’S MAIDEN NAME

HOME PHONE                                      E-MAIL ADDRESS

BUSINESS PHONE

SCHOOLING

HAVE YOU EVER BEEN IN THE MILITARY
HONORABLE DISCHARGE                             YES             NO

NAME OF BUSINESS

ADDRESS OF BUSINESS

HOURS OF BUSINESS

IDENTIFY FORMS OF FINANCING (THIS MUST BE PROVIDED OR APPLICATION WILL BE
REFUSED BY WORCESTER POLICE DEPARTMENT)
MORTGAGE: $                                                      SELLER:          $
CASH:          $                                                 OTHER (SPECIFY): $
Document all sources (e.g. – loan papers, checking accounts, stock sales, etc.)
    IF CORPORATION PLEASE FILL OUT FOLLOWING
                  INFORMATION

LIST OFFICERS & DIRECTORS
PRESIDENT NAME:                NAME:
ADDRESS:                       ADDRESS:


VICE PRESIDENT NAME:           NAME:
ADDRESS:                       ADDRESS:


TREASURER:                     NAME:
ADDRESS:                       ADDRESS:
                          APPROVAL SHEET

POLICE DEPARTMENT________________________________________

PUBLIC HEALTH______________________________________________

INSPECTIONAL SERVICES______________________________________

CHAPTER 304 CERTIFICATE___________________________________
                               CERTIFICATION OF COMPLIANCE WITH
                                WORCESTER REVISED ORDINANCES
                                GOVERNING REVENUE COLLECTION

Pursuant to M.G.L. c. 40, section 57 and Worcester Revised Ordinances, Chapter 11, Article 2, Section 1,
et. Seq., I hereby certify, under the pains and penalties of perjury, that the undersigned applicant, and all
parties having an ownership interest therein have complied with the laws of the Commonwealth of
Massachusetts and the City of Worcester regarding payment of all local taxes, fees, assesments,
betterment’s or any other municipal charges of any kind.

GIVE FULL NAMES AND RESIDENCES OF ALL PERSONS AND PARTIES INTERESTED

IN THIS APPLICATION

(Give first and last name if full: in case of a corporation give names of President, Treasurer and Manager,
and in case of firms, give names of individuals members)

1        IF A PROPRIETORSHIP
         Name of Owner
         Business Address
         Home Address
         Business Phone                                         Home Phone

2        IF A PARTNERSHIP
         Full names and addresses of all partners
         NAMES                                                            ADDRESS


Business Address
Business Phone

3        IF A CORPORATION
         Full legal name
         State of incorporation
         Principal place of business
         Principal place of business in Massachusetts

Officers in Corporation
         NAME                                                             TITLE



4        If a Trust
         Name of Trust
         Business Address

NAMES OF TRUSTEES                                                                           ADDRESS
(Use additional sheets if necessary)
DATED THIS                           DAY OF

By Name
Title
Business Address
Social Security or Federal I.D. No.
                                      CERTIFICATE OF COMPLIANCE
             PROVIDING COMPLIANCE WITH THE WORKERS’ COMPENSATION ACT

Section 25C of Chapter 152 Massachusetts Laws requires that every local licensing authority shall withhold
the issuance or renewal of a license or permit to operate a business or to construct a building(s) in the
Commonwealth until it has received acceptable evidence of compliance with the Worker’s Compensation
Insurance coverage required by law.

As a person or company seeking a license or permit to operate a business or to construct buildings or the
renewal of such a license or permit, you must supply one of the following by attaching it to the
CERTIFICATE OF COMPLIANCE.

(Please check one):

( )      A certificate of insurance showing workers’ compensation insurance in effect as of the date upon
         which issuance or renewal of a license or permit is requested

( )      A copy of a policy of workers’ compensation insurance in effect as of the date upon which the
         issuance or renewal of the license or permit is requested

In certain circumstances, listed below, workers’ compensation insurance is not required. If one of the
situations applies to you, please check off the appropriate exemption and sign the statement where indicated
before a Notary Public, who will then notarize the sworn statement:

COMMONWEALTH OF MASSACHUSETTS)
COUNTY OF WORCESTER          ) SS.

( )      I am self employed and have no employees who work for me, and do all the work of my business,
         named
         at                               , Worcester, myself. Therefore, I am not required to obtain
         workers’ compensation insurance.

( )      I and                       are the owners of the business named
         at                                   , Worcester and we have no employees. Therefore, we are not
         required to obtain workers’ compensation insurance.

I certify that the above is true and correct under the pains and penalties of perjury this
day of                                 20
                                                         Signature

Sworn to and subscribed before me this
day of                            20
                                                                           Notary Public
                                                                           My Commission expires
I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns
and paid all state taxes required under law.



*Signature of Individual                                By: Corporate Officer
or Corporate Name (Mandatory)                           (Mandatory, if Applicable)


**Social Security #(Voluntary)
or Federal Identification Number

*        This license will not be issued unless this certification clause is signed by the applicant

**       Your Social Security Number will be furnished to the Massachusetts Department of Revenue to
         determine whether you have met tax filing or tax payment obligations. Licensees who fail to
         correct their non-filing or delinquency will be subject to license suspension or revocation. This
         request is made under the authority of Mass. G.L. c. 62C s. 49A.
                               PARKING INFORMATION
Is this a new of existing establishment?                       Yes                         No

A new establishment will require parking approval (1 space per two seats) from the Planning Board (over
eight spaces)

If an existing establishment, are you proposing to increase the seating or occupancy?

Yes                                            No

If yes, any increase in occupancy will require one space for each two seat increase in allowed seating. Also,
the parking lot must be approved by the Planning Board.

*
What is the occupancy for this establishment

How many parking spaces are there

Where is the parking located

Please provide a copy of any leases for parking spaces

*You must contact the Department of Inspectional Services and they will determine the occupancy and
the amount of parking required for this establishment.

For further information please contact the Department of Inspectional Services 799-1198.

Please sign this application and also have someone from the Department of Inspectional Services sign
this form stating that they have reviewed the occupancy and parking lot requirements with you.


Department of Inspectional Services


Applicant
                                                                                                Commonwealth of Massachusetts
                                                                                             Alcoholic Beverages Control Commission
                                                                                                 239 Causeway Street, First Floor
                                                                                                        Boston, MA 02114


           STEVEN GROSSMAN                                                                                                                                                       KIM S. GAINSBORO, ESQ.
    TREASURER AND RECEIVER GENERAL                                                                          CORI REQUEST FORM                                                           CHAIRMAN


    The Alcoholic Beverages Control Commission has been certified by the Criminal History Systems Board to access conviction and pending Criminal Offender Record
    Information. For the purpose of approving each shareholder, owner, licensee or applicant for an alcoholic beverages license, I understand that a criminal record check
    will be conducted on me, pursuant to the above. The information below is correct to the best of my knowledge.


    ABCC LICENSE INFORMATION

    ABCC NUMBER:                                                         LICENSEE NAME:                                                                          CITY/TOWN:
    (IF EXISTING LICENSEE)



    APPLICANT INFORMATION

    LAST NAME:                                                                                     FIRST NAME:                                              MIDDLE NAME:


    MAIDEN NAME OR ALIAS (IF APPLICABLE):                                                                                               PLACE OF BIRTH:


    DATE OF BIRTH:                                                            SSN:                                                      ID THEFT INDEX PIN (IF APPLICABLE):


    MOTHER'S MAIDEN NAME:                                                                      DRIVER'S LICENSE #:                                          STATE LIC. ISSUED:


    GENDER:                                                 HEIGHT:                                                                 WEIGHT:                      EYE COLOR:


    CURRENT ADDRESS:


    CITY/TOWN:                                                                                                             STATE:                    ZIP:


    FORMER ADDRESS:


    CITY/TOWN:                                                                                                             STATE:                    ZIP:



    PRINT AND SIGN

    PRINTED NAME:                                                                                      APPLICANT/EMPLOYEE SIGNATURE:



    NOTARY INFORMATION

         On this                                                                     before me, the undersigned notary public, personally appeared


    (name of document signer), proved to me through satisfactory evidence of identification, which were

    to be the person whose name is signed on the preceding or attached document, and acknowledged to me that (he) (she) signed it voluntarily for
    its stated purpose.


                                                                                                                                                              NOTARY


                                                                                                                          Print Form
DIVISION USE ONLY
 REQUESTED BY:
                                            SIGNATURE OF CORI-AUTHORIZED EMPLOYEE
The DCJI Identify Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft
PIN Number by the DCJI. Certified agencies are required to provide all applicants the opportunity to include this
information to ensure the accuracy of the CORI request process. ALL CORI request forms that include this field are
required to be submitted to the DCJI via mail or by fax to (617) 660-4614.

								
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