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Conunonzuealth of Massaclnrsetts <br /> Alcoholic Beverages Control Commission <br /> " — 95 Fourth Street, Suite 3 <br /> Chelsea,MA 02150 <br /> JEA.VAI.LOR17.10,ESQ. CORI REQUEST FORM <br /> C1IAIRMAV <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. I CITY/TOWN: Mashpee <br /> 'IF o STING---- I <br /> APPLICANT INFORMATION <br /> LAST NAME: Ko FIRST NAME: Mei Na MIDDLE NAME: <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OF BIRTH: Guangzhou China <br /> DATE OF BIRTH: (III SSN: ID THEFT INDEX PIN(IF APPLICABLE): <br /> MOTHER'S MAIDEN NAME: Peiying Liu DRIVER'S LICENSE 4: ` STATE LIC.ISSUED: Massachusetts <br /> GENDER: FEMALE HEIGHT: 5 5 . WEIGHT: 153 EYE COLOR: grown <br /> CURRENT ADDRESS: <br /> CITY/TOWN: Plymouth STATE: MA ZIP: 02360 —� <br /> FORMER ADDRESS: <br /> CITY/TOWN: (Plymouth STATE: MA ZIP: 02360 <br /> PRINT AND SIGN <br /> PRINTED NAME: Mel Nd KO APPLICANT/EMPLOYEE SIGNATURE: <br /> NOTARY INFORMATION <br /> On this C,*� Seviern 20+`lbefore me,the undersigned notary public,personally appeared Mel Na Ko <br /> (name of document signer),,proved to me through satisfactory evidence of identification,which were driver's license 1 <br /> to be the person whose name is signed on the preceding or attached document,and ack owledged to me that(he)(she)signed it voluntarily for <br /> its stated purpose. <br /> �1 NOTARY `✓ <br /> DIVISION USE ONLY —s,� JENNIFER M.DA CRUZ <br /> Notary Public <br /> F ' <br /> REQUESTED 0v Massachusetts <br /> I�GNANRE OFCORP AVTHORIZED ESN EME 9 <br /> of o My Commission Expires <br /> The DCII laenbfy Tl left index PIN Numoel Is to be completed by these applicants that have been issued an Iden city Theft ✓:M.. <br /> pIN Numbor by the DCII.Cerli ied agencies me requited to provide all applicants the opportunity to-hide this Dec 14,2023 <br /> into,h atnon Ip ensure the accuracy of its,,CORI request proce s ALL CORI request forms that include th"field are <br /> requited lu be submitted to the DOI Vla man or by fax to(617)660-4614 „, . <br />