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; -\ Commonwealth of Massachusetts <br /> Alcoholic Beverages Control Connnission <br /> 95 Fourth Street, Suite 3 <br /> Chelsea,lldA 02150 <br /> ,IEQ,V Al.LORIZ10,ESQ. CORI REQUEST FORM <br /> CMAIRMAN <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 Inc,pursuant <br /> to the above.The information below is correct to the best of my knowledge. <br /> ABCC LICENSE INFORMATION _ <br /> I <br /> ABCC NUMBER: 00073-RS•0670 LICENSEE NAME:Mashpee Oriental,Inc. i CITY/TOWN: Mashpee I <br /> iIF C%IS11Nv tfCEN$EfI -- <br /> APPLICANT INFORMATION <br /> j LAST NAME: Zou FIRST NAME: in Feng i MIDDLE NAME: <br /> I <br /> I <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE); PLACE OF BIRTH: Fuzhou China <br /> DATE OF B1RTh, SSN: ID THEFT INDE�X`PIN(IF APPLICABLE): I _� <br /> MOTHER'S MAIDEN NAME: Lin Oian Sin DRIVER'S LICENSE# I STATE LIC.ISSUED: jMeSSaC?1USettS��! <br /> I 'J <br /> i <br /> WEIGHT: EYE COLOR; <br /> 'GENDER: MALE I+11 HEIGHT: 5 � 6 '+' 170 Brown <br /> CURRENT ADDRESS: <br /> --- <br /> CITY(TOWN: E.Falmouth STATE:?MA ZIP: O2636 <br /> I <br /> FORMER ADDRESS: <br /> 71 CITY/TOWN: Quincy STATE: MA 21P: 02170 <br /> PRINT AND SIGN <br /> PRINTED NAME: Jln Feng ZOU APPLICANT/EMPLOYEE SIGNATURE; I l[ r I <br /> NOTARY INFORMATION C� <br /> On this I before me,the undersigned notary public,personally appeared in Feng ZoU <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 a wledged to me that(he)(she)signed it voluntarily for <br /> ;its stated purpose. <br /> i <br /> NOTARY <br /> DlytS101J USE ONLY 2�s — s,� JENNIFER M.DA CRUZ <br /> kkCLiLS1EUNy W ,7 � Notary Public <br /> SIGNAI , .I eanu,xrW1fDEEWiOVEk r Massachusetts <br /> '11fVIP WePh1y 1I,0M—PIN N.—W IIt—-.PIeted by thote apphl-tl that h—b—110ed aA Ide^bty Theft �J�sr 44C� My Commission Expires <br /> Olt,N,IIneOr by the CHIN CMIIhed eYcnc:et are*.4-,,d W Prot'Ide ail aPPI 1111 thn OOPOrl-Ay td—,,d0 Ihlt Dec 14,2023 <br /> :nlolmalwn tp¢.+ "tP<a.—q 01 the CORI regaet:PIOtett ALL CORI regpe t loans that Include W,field ate <br /> requllcd Iq be I.hmhied to the OCR via..it pr by laa Lq(617)604614. <br />