06/03/2019 BOARD OF SELECTMEN Agenda Packet

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APPLICATION FOR AMENDMENT-Change of Officers Stock or Ownershi Interest I CURRENT OFFICERS STOCK OR OWNERSHIP INTEREST List the individuals and entities of the current ownership. Attach additional pages if necessary utilizing the format below. Name of Principal Title/Position Percentage of Ownership ................ Darby Ziruk Founder 50% Name of Principal Title/Position Percentage of Ownership [Damien Ziruk Operations 50% Name of Principal Title/Position Percentage of ownership Name of Principal Title/Position Percentage of ownership Name of Principal Title/Position Percentage of ownership Name of Principal Title/Position Percentage of ownership 4. INTEREST IN AN ALCOHOLIC BEVERAGES LICENSE Does any individual or entity identified in question 2,and applicable attachments, have any direct or indirect,beneficial or financial interest in any other license to sell alcoholic beverages? Yes F-1 No Z If yes,list in table below.Attach additional pages,if necessary,utilizing the table format below. Name License Type License Name Municipality S. PREVIOUSLY HELD INTEREST IN AN ALCOHOLIC BEVERAGES LICENSE Has any individual or entity identified identified in question 2,and applicable attachments,ever held a direct or indirect,beneficial or financial interest in a license to sell alcoholic beverages,which is not presently held? Yes ❑ No If yes,list in table below.Attach additional pages,if necessary,utilizing the table format below. Name License Type License Name Municipality * See adendum page 6. DISCLOSURE OF LICENSE DISCIPLINARY ACTION Have any of the disclosed licenses listed in question 4 or 5 ever been suspended,revoked or cancelled? Yes 0 No Z If yes,list in table below.Attach additional pages,if necessary,utilizing the table format below. Date of Action Name of License City Reason for suspension,revocation or cancellation 3