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Cornrnonwealth of Massachrsetts <br /> Alcoholic Beverages Control Colnnlisslon <br /> 95 Fourth Street,Suite 3 <br /> Chelsea,MA 02150 <br /> Jf-A.V,V,LORIZla,ESQ, CORI REQUEST FORM <br /> CIIAINr'NAN <br /> The Alcoholic Beverages Control Commission ("ABC'Ct) has been certified by the C:rinlinal History Systems Board to access <br /> conviction and pending Criminal Offender Record Inl'<rrniation (,,CORI,,). For the purpose of approving each shareholder, owner, <br /> licensee or applicant for an alcoholic beverages license;, t understand than a criminal record check will bc condticted on n7e, Pursuant <br /> to the above,The information below is correct to the best of Iny knowledge. <br /> ABCC LICENSE INFORMATION _ <br /> ABCC NUMBER: 00073-RS•0670 LICENSEE NAME:Mashpee Oriental,Inc. CITY/TOWN: Mashpee I i <br /> 't°CxItTYC KCnieU <br /> APPLICANT INFORMATION <br /> LAST NAME: Ren �Y FIRST NAME: =F.ngY.n MIDDLE NAME; L <br /> JJJ <br /> I <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): ; PLACE OF BIRTH: Fuzhou China <br /> F <br /> t �� <br /> I DATE OF BIRTH: SSN: C ID THEFT INDEX PIN(IF APPLICABLE): I <br /> l � ���..JII L— <br /> MOTHER'S MAIDEN NAME: Wanlin Lin -� DRIVER'S LICENSE#. ( STATE LIC.ISSUED: Massachusetts <br /> GENDER: MALE „ j HEIGHT: 6 1 + WEIGHT; 140 EYE COLOR; Brown I <br /> __._...._......._ ..._.............._..........._. <br /> __ __ II <br /> CURRENT ADDRES5: <br /> rCfTY/TOWN; E.Falmouth STATE: MA ZIP; 02536 <br /> I <br /> FORMER ADDRESS; <br /> I <br /> CITY/TOWN: Changle China STATE: ZIP: 350200 <br /> PRINTANOSIGN r� <br /> PRINTED NAME: Fang Yan.Ren —�� APPLICANT/EMPLOYEE SIGNATURE: <br /> NOTARY INFORMATION <br /> tri <br /> i <br /> On this hclatrFo �(M,r before me,the undersigned notary public,personally appeared Fang Yan Ren <br /> I <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 aq nowledged to me that(he)(she)signed it voluntarily for[ <br /> ;its stated purpose, I <br /> l j <br /> NOTARY <br /> Ah AL <br /> JENNIFER M.DA CRUZ <br /> p)VISION USEOWY Notary Public <br /> N <br /> I Massachusetts <br /> xtat,cstlD 6r ! � <br /> -- Yi:7'U�t t3�{ :5U tf rtl f: r.M LOYEe �uj� My Commission Expires <br /> ilh UCH I.t•oLlI Thett codes I`N hvndrW:s to oe[ompleled by the,e Jpgbwot,dial flan WL'I+I—d an lalmnty Thelt M Dec 14,2023 <br /> 1I1 Na be,h,Ib,DJ, C,whe!d a'."I-o 1.plo, 1 A11 aVnhtdoh Iht•O e,U —ty W—1.61 01131 <br /> inlotmn:ioe 1,--,Iho attota:y dt the LOW rtq—1 otacetS ALL COKI Yegoesl(6-1 that hid.de th-s 11eid <br /> regohed to bM.b.;tt.d so tM DOI W.mall of by far to(617)$60,4614 <br />