Beneficial Interest Contact - Individual Page 2
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2ALCOHOLIC BEVERAGES CONTROL COMMISSION
BENEFICIAL INTEREST CONTACT - Individual (continued)
Ownership / Interest
If you hold a direct beneficial interest
Using the definition above, do you hold a direct
Direct
Indirect
in the proposed licensee, please list
or indirect interest in the proposed licensee?
the % of interest you hold.
If you hold an indirect beneficial interest in this license, please complete the Ownership / Interest Table below.
Ownership / Interest
If you hold an indirect interest in the proposed licensee, please list the organization(s) you hold a direct interest in which, in
turn, hold a direct or indirect interest in the proposed licensee. These generally include parent companies, holding companies,
trusts, etc. A Beneficial Interest - Organization Form will need to be completed for each entity listed below.
Name of Beneficial Interest - Organization
FEIN
Other Beneficial Interest
List any indirect or indirect beneficial or financial interest you have in any other Massachusetts Alcoholic Beverages License(s).
Name of License
Type of License
License Number
Premises Address
Familial Beneficial Interest
Does any member of your immediate family have ownership interest in any other Massachusetts Alcoholic Beverages Licenses?
Immediate family includes parents, siblings, spouse and spouse's parents. Please list below.
Relationship to You
ABCC License Number
Type of Interest (choose primary function) Percentage of Interest
Prior Disciplinary Action
Have you ever been involved directly or indirectly in an alcoholic beverages license that was subject to disciplinary action? If
yes, please complete the following:
Date of Action
Name of License
State City
Reason for suspension, revocation or cancellation
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