Amendment Application For A Change Of Manager - Massachusetts Alcoholic Beverages Control Commission Page 4

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APPLICATION FOR A NEW RETAIL ALCOHOLIC BEVERAGES LICENSE
4. MANAGER CONTACT
The Manager Contact is required and is the individual who will have day-to-day, operational control over the liquor license.
Salutation
First Name
Middle Name
Last Name
Suffix
Social Security Number
Date of Birth
Primary Phone:
Email:
Mobile Phone:
Place of Employment
Alternative Phone:
Fax Number
Citizenship / Residency / Background Information of Proposed Manager
Are you a U.S. Citizen?
Do you have direct, indirect, or
Yes
No
Yes
No
financial interest in this license?
Have you ever been convicted of a state,
Yes
No
federal, or military crime?
If yes, percentage of interest
If yes, attach an affidavit that lists your convictions with an explanation for each
If yes, please indicate type of Interest
(check all that apply):
Have you ever been Manager of Record of a
Yes
No
Officer
Sole Proprietor
license to sell alcoholic beverages?
Stockholder
LLC Manager
LLC Member
Director
If yes, please list the licenses
Partner
Landlord
for which you are the current
or proposed manager:
Contractual
Revenue Sharing
Management Agreement
Other
Please indicate how many hours per week you intend to be on the licensed premises
Employment Information of Proposed Manager
Please provide your employment history for the past 10 years
Date(s)
Position
Employer
Address
Phone
Prior Disciplinary Action of Proposed Manager
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
2
PROPOSED MANAGER MUST COMPLETE A
CORI REQUEST
FORM

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