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5 <br /> Commonwealth o,f Massachusetts <br /> Alcoholic Beverages Control Commission <br /> 239 Causeway Street,First Moor <br /> Boston,.LA 02114 <br /> CORI RF U�ST FORM JEA.NM.LORLZIO�E� . <br /> DEBORAHB.GOLDBERG � <br /> TREASURER AND RECEIVER GENERAL CHAIRMAN <br /> The Alcoholic Beverages Control Commission ("ABCC") has been certified by the Criminal History Systems Board to access <br /> conviction and pending Criminal Offender Record Information ("CORI"). For the purpose of approving each shareholder, owner, <br /> licensee or applicant for an alcoholic beverages license,I understand that a criminal record check will be conducted on me,pursuant <br /> to the above.The information below is correct to the best of my knowledge. <br /> ABCC LICENSE INFORMATION <br /> ABCC NUMBER: P5WM-19-0020 LICENSEE NAME:Darby's Natural Markets LLC CITY/TOWN: Mashpee <br /> IIF EXISTING LICENSEE) <br /> APPLICANT INFORMATION <br /> LAST NAME: Eames FIRST NAME: Ryan MIDDLE NAME: Patrick <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OF BIRTH: Plymouth,MA <br /> DATE OF BIRTH: SSN: ID THEFT INDEX PIN(IF APPLICABLE): <br /> MOTHER'S MAIDEN NAME: DRIVER'S LICENSE#: STATE LIC.ISSUED: Massachusetts <br /> GENDER: MALE '*' HEIGHT: 5 g El <br /> WEIGHT: 225 EYE COLOR: brown <br /> ....................... .....E <br /> __J1 <br /> CURRENT ADDRESS: <br /> CITY/TOWN: STATE: MA ZIP: C <br /> FORMER ADDRESS: <br /> CITY/TOWN: STATE: MA ZIP: <br /> PRINTANA SIGN <br /> PRINTED NAME: Ryan Eames APPLICANT/EMPLOYEE SIGNATURE: <br /> NOTARYINFORMATION <br /> On this 1 before me,the undersigned notary public,personally appeared <br /> (name of document signer),proved to me through satisfactory evidence of identification,which were - 1�- <br /> to be the person whose name is signed on the preceding or attached document,and acknowledged to me that(he)(she)signed it voluntarily for <br /> its stated purpose. - <br /> i ZOLYMPIA ZON ,� � <br /> PUNIC, of M� <br /> - r+>s Matt+i s,20M NOTARY <br /> commmm DIVISION USE ONLY <br /> REQUESTED 8Y: <br /> SIGNATURE OF COR!-ANN—ORIZED EMPLOYEE <br /> The DCJI Identify Theft Index PIN Number is to be completed by those applicants that have been issued an Identity Theft <br /> PIN Number by the DCII.Certified agencies are required to provide all applicants the opportunity to Include this <br /> Information to ensure the accuracy of the CORI request process. ALL CORI request forms that Include this field are <br /> required to be submitted to the DCII via mail or by€ax to(617)SGD4634. <br />