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The Commonwealth of h9massachusels <br /> Alcoholic Beverages Control CommWon <br /> 239 Causeway Sind,Boston KA 02114 <br /> wwW.MdsS, o ahcc <br /> 0 �,I Il, <br /> AMENDMENT-Change a of Manager ' �' i 111' a <br /> _ <br /> 1,BUSINESS ENTR INFORMATION <br /> Entity Name Municipality ABCC License Number <br /> [25 Market Street Inc Mashpee 00069•RS 0610 <br /> 2,APPLICATION CONTACT <br /> The application contact is the person who should be contacted with any questions regarding this application, <br /> Name Title Email Phone <br /> Susan J,Musto :Treasurer <br /> 3A.MANAGER INFORMATION <br /> The individual that has been appointed to manage and control ofthe licensed business and premises. <br /> Proposed Manager Name IsusanI Musto Date OfBirth SSN <br /> Residential Address <br /> Email Phone <br /> Please Indicate how many hours perweek last-Approved License Manager ohm F Reid <br /> you intend to be on tine licensed premises <br /> B. EN BA UN ORM <br /> U <br /> C,Ves <br /> Are you a U,S,Citizeml" ('No *Manager must bQ U.S.citizen <br /> Ifyes,attach one fte followin as proof of citizenshipp US Passport,Voter's Certificate,Birth Certificate or Naturalization Papers. <br /> Have you ever been convictedIstate,federal,or mil'uarycrimel r.Yes 6 No <br /> if yes,fill out the table below and attach an affidavit providing the details of any and all convictions.Attach additional pages,if <br /> necessary,utilizing the format below, <br /> Date Municipality Charge Disposition <br /> 3 , EMPLOYMENT INFORM ATION <br /> Please provide your employment history.Attach additional pages,If necessary, utilizing the format below. <br /> Start Date End Date Position Employer Supervisor Name <br /> E04/O112W) 1pres Treasurer' 25 Market StInc Iamowner <br /> O pres president SMC Business Services Inc I am owner <br /> 3D.PRIOR DISCIPLLNARY ACTION <br /> Have you held a beneficial or financial Interest in,or been the manager of,a license to sell alcoholic beverages that was subject to <br /> disciplinary actlonl C yes CO.& If yes,please fill out the table,Attach additional pages,if necessary,utilizing the format below. <br /> Date of Action Name of license State JCity Reason for suspension,revocation or cancellation <br /> Ihereby swearunder the painsandpenaltiesof perJruythatthe InforwaVon I have provided In this a#icat[onIstrue and accurate: <br /> Manager'sSignature Date Eii <br />