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APPLICATION FOR AMENDMENT-Change of Officers, Stock or Ownership Interest <br /> 2. 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 residents. <br /> • If you area Multi-Tiered Organization,please attach a flowchart 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 /> Ricky Zhong QingHuangF_ <br /> Title and or Position Percentage of Ownership Director/LLC Manager US Citizen MA Resident <br /> Shareholder 5 shares I I (-.Yes {:;No 1 (: Yes ( No (*'.Yes (` No <br /> Name of Principal Residential Address SSN DOB <br /> [An Feng Zou 1 1 711 <br /> 7 <br /> Title and or Position Percentage of Ownership Director/LLC Manager US Citizen MA Resident <br /> [Shareholder 18.333 shares C.Yes C• No (::Yes (:No C: Yes ( :No <br /> Name of Principal Residential Address SSN DOB <br /> [Ah Chin Liu <br /> Title and or Position Percentage of Ownershi Director/LLC Manager US Citizen MA Resident <br /> Shareholder 5 shares ( Yes 1 6 :Yes C N (-*:,Yes C No <br /> Name of Principal Residential Address SSN DOB <br /> FiennyShum <br /> Title and or Position Percentage of Ownershi Director/LLC Manager US Citizen MA Resident <br /> [Shareholder 15 shares {`:Yes (:-No C(::Yes (`.No (`:Yes (:,:No <br /> Name of Principal Residential Address SSN DOB <br /> Pna Yang <br /> Title and or Position Percentage of Ownershi Director/LLC Manager US Citizen MA Resident <br /> Treasurer/Director/Shareholder 13.333 shares (*'Yes (`:No I t�'Yes Io <br /> Name of Principal Residential Address SSN DOB <br /> Fm__el Na Ko <br /> Title and or Position Percentage of Ownershi Director/LLC Manager US Citizen MA Resident <br /> President/Director/Shareholder 10 shares t`:Yes (' No (: Yes C No (: Yes C 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 ( Yes ( 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 copy of the management agreement. C^Yes C: No 2 <br />