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APPLICATION FOR AMENDMENT-Change of officers Stock or Owners hl Interest <br /> . PROPOSED OFFICERS STOCK OR OWNERSHIP INTEREST <br /> List all individuals or entities that will have a direct or indirect,beneficial or financial interest in this license(E.g.Stockholders,officers, <br /> Directors,LLC Managers,LLP Partners,Trustees etc.).Attach additional page(s)provided,if necessary,utilizing Addendum A. <br /> * The individuals and titles listed in this section must be identical to those filed with the Massachusetts Secretary of State. <br /> * The individuals identified in this section,as well as the proposed Manager of Record,must complete a CORI Release Form. <br /> ■ Please note the following statutory requirements for Directors and LLC Managers: <br /> On Premises(E.g.Restaurant/Club/Hotel)Directors or LLC Managers -At least 50%must be US citizens; <br /> Off Premises(Liquor Store)Directors or LLC Managers -All must be US citizens and a majority must be <br /> Massachusetts eesidents. <br /> If you are a Multi-Tiered Organization,please attach a flow chart identifying each corporate interest and the individual owners of <br /> each entity as well as the Articles of organization for each corporate entity. Every individual must be identified in Addendum A. <br /> Name of Principal Residential Address SSN DOB <br /> Roryer Eames - <br /> L _ <br /> Title and or Position Percentage of Ownershi Director/LLC Manager US Citizen MA Resident <br /> CEO S0a <br /> �° (:Yes (7 No (F Yes '' No 's Yes No <br /> Name of Principal Residential Address SSN DOB <br /> Ryan Eames <br /> L ..... <br /> Title and or Position Percentage of Ownershi Director/LLC Manager US Citizen MA Resident <br /> COO 20% �`t Yes (7 No :Yes C`.No ( �Yes C No <br /> Name of Principal Residential Address SSN DOB <br /> Title and or Position Percentage of Ownershi Director/LLC Manager US Citizen MA Resident <br /> Yes (`No C Yes C,No es ( No <br /> Name of Principal Residential Address SSN DOB <br /> Title and or Position Percenta e of Ownershi Director/LLC Manager US Citizen MA Resident <br /> Yes C No (7 Yes (7 No 'Yes C,No <br /> Name of Principal Residential Address SSN DDB <br /> Title and or Position Percentage of Ownership Director/LLC Manager US Citizen MA Resident <br /> J" <br /> C"Yes C No C Yes C No (' Yes ( No <br /> Name of Principal Residential Address SSN DOB <br /> Title and or Position Percentage of Ownershi Director/LLC Manager US Citizen MA Resident <br /> C Yes C.Nv (' Yes C No ( Yes (' No <br /> Additional pages attached? '` Yes No <br /> CRIMINAL HISTORY <br /> Has any individual listed in question 2,and applicable attachments,ever been convicted of a C Yes f No <br /> State,Federal or Military Crime?If yes,attach an affidavit providing the details of any and all convictions. <br /> MANAGEMENT AGREEMENT <br /> Are you requesting approval to utilize a management company through a management agreement? <br /> Please provide a co of the management agreement. r Yes (WNo 2 <br /> p copy g <br />