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Cminonwealth of Massachusetts <br /> Alcoholic Beverages Control Commission <br /> 95 Fourth Street,Saite 3 <br /> Chelsea,MA 021,50 <br /> AUVAI.L 01?IZIO,L--SQ. CORI REQUEST FORM <br /> C11AIRAIIIN <br /> The Alcoholic Beverages Control Commission ("ABCC") has been certified by the Criminat History Systems Board to access <br /> conviction and pending Criniinat Offender Record Triformation ("CORI"), For the purpose or approving each shareholder, owner, <br /> licensee or applicant for an alcoholic beverages license,I understand that a criniinal record check will be conducted or)me,pursuant <br /> to the above.The inf'ormation below is correct'lo the best of my knowledge. <br /> ABCC LICENSE INFORMAVON <br /> AUCC NUMBER- 0073-RS-01670 LICENSEE NAME:IMashpee Oriental,Inc. CITY/TOWN:Fm ashpee <br /> APPLICANT INFORMATION <br /> MIDDLE NAME:LAST NAME: FIRST NAME: Chao Chun Fl - F <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OF BIRTH: Fuzhou China <br /> DATE OF BIRTH: SSN: ID THEFT INDEX PIN(IF APPLICABLE): <br /> MOTHER'S MAIDEN NAME; Yilin Lin i DRIVER'S LICENSE STATE LIC,ISSUED: <br /> GEN I DER: MALE HEIGHT: 5 WEIGHT; EYE COLOR: 1Brown <br /> j CURRENT ADDRESS: <br /> i <br /> CITY/TOWN: T.FaImputh STATE <br /> : MA ZIP: <br /> FORMER ADDRESS: <br /> CITY/TOWM !Freeport STATE: NY ZIP: 111520 <br /> .............. J <br /> PRINTAND S145N <br /> I/ <br /> PRINTED NAME: Chao Chun LinAPPLICANT/EMPLOYEE SIGNATURE: i fj V <br /> NOTARYINFORMATION <br /> On this before me,the undersigned notary public,personally appeared Chao Chun Lin <br /> ............. <br /> '(name of document signer),proved to me through satisfactory evidence of identification,which were drivers license <br /> Ito be the person whose name is signed on the preceding or attached document,an a knowledge to me hat K(she)simed it voluntarily fort <br /> liit:5 stated purpose. <br /> 9 NOTARY <br /> 011115ION USE ONLY JENNIFER M.DA CRUZ <br /> Notary Public <br /> Massachusetts <br /> been <br /> -.,ow bl�th— pot,suls OW havehabeenissued.11 IduMll,I'!,it My Commission Expires <br /> It-,00i Idoluily melt J�1­I'll,1111001 15 1.b�I, <br /> P114 Nu bet ty jlw O:JI (scrtImd ott.nllu,—nqua,,I1 1.pl.id all Ipohl,allr the w.11-Al,I."'Outu,the Dec 14,2023 <br /> 1—?more the accuracy of Itle CORI 1e4ust 0­e,, 0,U CORI request larmt that lAtivdt IhI&field are <br /> Ieq.11tul to be I,ulufttted I.the 047J)We IIIIN III by tart-ISM 6604614, <br />