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CornmonZvealth of Massachusetts <br /> Alcoholic Beverages Control Commission <br /> -- 95 Fourth Street,Suite 3 <br /> Chelsea,MA 02150 <br /> JEAV M.L0PdZ10,ESQ. CORI REQUEST FORM <br /> 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: 00073-RS-0670 LICENSEE NAME:Mashpee Oriental,Inc. CITY/TOWN: Mashpee <br /> (IF EXISIING LICENSED <br /> APPLICANT INFORMATION <br /> LAST NAME: Yang FIRST NAME: Lino MIDDLE NAME: <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): Lina Yang PLACE OF BIRTH: Guangzhou China <br /> DATE OF BIRTH: SSN: IDTHEFT INDEX PIN(IF APPLICABLE): <br /> MOTHER'S MAIDEN NAME: Guang Di Liu DRIVER'S LICENSE k: STATE LIC.ISSUED: Md55dCITU5ett5 <br /> GENDER: HEIGHT: S WEIGHT: 120 EYE COLOR: grown <br /> CURRENT ADDRESS: <br /> CITY/TOWN: E.Falmouth STATE: MA ZIP: 02536 —� <br /> FORMER ADDRESS: <br /> CITY/TOWN: Falmouth STATE: MA ZIP: 22540 <br /> PRINT AND SIGN �--^� <br /> PRINTED NAME: Llrld YangAPPLICANT/EMPLOYEE SIGNATURE: l — <br /> NOTARY INFORMATION <br /> On this �— before me,the undersigned notary public,personally appeared Lina Yang —� <br /> (name of document signer),proved to me through satisfactory evidence of identification,which were driver's license <br /> to be the person whose name is signed on the preceding or attached document,and acpnowledged to me that(he)(she)signed it voluntarily,for <br /> its stated purpose. , <br /> I <br /> NOTARY <br /> i <br /> JENNIFER M,DA CRUZ <br /> DIVISION USE ONLY e°� L�\ <<� Notary Public <br /> REOUESTEDRY Massachusetts <br /> °s My Commission Expires <br /> SiGNAIURE OFCORI-AUTHORIZED EMPLOYEEJA, CC <br /> The DUI Identify Theft In <br /> PIN Number Is to be completed by those applicants that have been issued an hi'may,Theft S'eply�y1 Dec 14,2023 <br /> PIN Number by the OCII Certified ae,r-,are required to provide all appli.ms the opportunity to include this <br /> Informatmn to ensure the accuracy of the CORI request process ALL CORI request forms that Include this fie{d are <br /> required to be submitted to the DUI vi mail or by fax 1o(617)6W,4614. <br />