Liquor License Questionnaire

Questionnaire for Liquor License Application

No.

Question

Response

1

Type of Transaction – Mark all that apply

New License

Transfer of License

Change of Manager

Transfer of Stock

New Officer / Director

Change of Location

Alter Premises

Pledge of License to Lender/Creditor

Pledge of Stock to Lender/Creditor

Other (Please specify)

2

Name of Licensee – Official Name

3

Name, Address, Date of Birth, Social Security Number & Phone Number for each Officers, Directors & Shareholders, with # of shares, of Licensee Entity

President

Treasurer

Clerk

Director(s)

Shareholder(s)

4

Are All Officers, Directors & Shareholders United States Citizens

Yes

No

5

If No, specify citizenship

6

Number of Shares Authorized

7

Number of Shares Issued

8

Name of Business – DBA Name

9

Federal Identification Number

10

Local Address of Licensee

11

License Class – Annual or Seasonal

12

License Category – Mark all that apply

All Alcohol

Wine & Malt

Malt Only

Wine Only

Wine & Malt w/ Cordials Permit

13

Type of License – Mark all that apply

Club

General on Premise

Innholder

Package Store

Restaurant

Tavern

Veterans Club

Other (Please specify)

14

Phone number at Premise

15

Seating Capacity of Premises

16

Occupancy Number of Premises

17

Will there be construction, remodeling, redecorating or building on the Premises for the License

Yes

No

18

If Yes, give exact description of construction, remodeling, redecorating or building to be completed, including estimated costs, construction schedule & source of construction financing

19

Will Premises be Owned

Yes

No

20

If Yes, provide name of owning entity

21

If No, provide Landlord info including

Name

Phone Number

Address

Date of Birth

Social Security Number

Rent Amount

Dates of Lease

22

Are assets being purchased

Yes

No

23

If Yes, provide Purchase Price & copy of Purchase & Sale Agreement

Equipment

Inventory

Furniture

License

Goodwill

Premises

24

Identify Source of Financing and provide evidence of source

Mortgage

Cash

Seller

Other (Please specify)

25

Will inventory be pledged

Yes

No

26

If Yes, to whom

27

Will license be pledged

Yes

No

28

If Yes, to whom

29

Will corporate stock be pledged

Yes

No

30

If Yes, to whom & how many shares

31

Do you have or have you had any other licenses

Yes

No

32

If Yes, please provide

Type of License

Licensee Name and Address

Date Ownership Terminated

Reason for Termination

Provide copies of any and all action with City/Town Licensing Board & ABCC

33

Name of Transferring Entity

34

Name and Address for each Officers, Directors & Shareholders, with # of shares, of Transferring Entity

President

Treasurer

Clerk

Director(s)

Shareholder(s)

35

Name of On-Premises Manager

36

Social Security Number of On-Premises Manager

37

Home Address of On-Premises Manager

38

Telephone Number of On-Premises Manager

Home

Work

39

Place of Birth of On-Premises Manager

40

Date of Birth of On-Premises Manager

41

Is On-Premises Manager a Registered Voter – Mark answer that applies

Yes

No

42

Is On-Premises Manager a U.S. Citizen – Mark answer that applies

Yes

No

43

If No, provide Naturalization information

Court

Date

Proof of Citizenship

44

Father’s Name

45

Mother’s Name (w/ Maiden Name)

46

Does On-Premises Manager have a Criminal Record

Yes

No

47

If Yes, Please explain

Describe Offense

Specific Charge

Disposition

48

Does On-Premises Manager have prior experience in Liquor Industry

Yes

No

49

If Yes, Please explain in detail

50

Does On-Premises Manager have a financial interest, direct or indirect, in any other liquor license, permit or certificate

Yes

No

51

If Yes, please explain in detail

52

Please list On-Premises Manager Employment for last Ten (10) Years

Include:

Dates

Position

Employer

Address

Telephone Numbers (if known)

53

Approx Hours per week On-Premises Manager will spend on Premises

A Contemporary Law Firm with Traditional Values
Office Location

Law Office of Mark L. Janos, P.C.
6 Harris Street
Newburyport, MA 01950
Map/Directions

Call 1-844-JANOSLAW
direct: 844-526-6752

Visa and Master Card
Law Office of Mark L. Janos, P.C. Attorneys Newburyport, Massachusetts