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y� Comynanuwalth of Massachnsefts <br /> r=;x; Alcoholic Beverages Control Commission <br /> ' 95 Fosirth Street,Suite 3 <br /> Chelsea,MA 02150 <br /> JLA,V IUrI LORI&O,ESQ. C.O.K.-REQUEST FORM <br /> C11AIRnMAN <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: 0073-RS-0670 LICENSEE NAME:Mashpee Oriental,Inc. CITY/TOWN: Mashpee `! <br /> tlf t%I.iTING UCEIi5EE) �,� �---------� I i <br /> APPLICANT INFORMATION <br /> —I' <br /> LAST NAME: Hung FIRST NAME: 51paiu MIDDLE NAME; <br /> i <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE); (5ipaiu Xu i PLACE OF BIRTH: aiwan <br /> DATE OF BIRTt 55N: ID THEFT INDEX PIN(IF APPLICABLE): <br /> MOTHER'S MAIDEN NAME: Yueni Liang l DRIVER'S LICENSE k: STATE LIC.ISSUED: !Massachusetts <br /> GENDER: FEMALE r HEIGHT; 5 r } WEIGHT: 135 EYE DOLOR: grown <br /> �� _ <br /> CURRENT ADDRESS: l <br /> CITY/TOWN: E.Falmputh T STATE: MA ZIP: 02536 <br /> FORMER ADDRESS: <br /> It <br /> CITY/TOWN: £.Falmouth STATE: MA ! ZIP: 02516 <br /> ! <br /> t� <br /> PRINT AND SIGN <br /> PRINTED NAME: Slpaiu Hong i APPLICANT/EMPLOYEE SIGNATURE: in 3 <br /> NOTARY INFORMATION <br /> On this > tll- `3 d 2 -- <br /> ��G i before me,the undersigned notary public,personally appeared Sfpaiu Hong-- —� <br /> i <br /> {name of document signer),proved to me through satisfactory evidence of identification,which were driver's license <br /> j <br /> jto be the person whose name is signed on the preceding or attached document,and acknowledged to me that(he)(she)signed it voluntarily for; <br /> jits'stated purpose. <br /> NOTARY <br /> DIVISION USEDNLY <br /> JENNIFER M.DA CRUZ <br /> i u!qutsnnnr I �� Notary Public <br /> v:1A!UB O CRt•AUf JRr/t1rt.:PtiS Ft Massachusetts <br /> DU <br /> I r tdrnirly r!Mf(indlK P\ um Nte,:5 to b —1 e—Pi by 0-11 apAl:fabt5 taut baye been—,d an ldentdy 11"l,I ay <br /> Em mnbr.by me ocn Eer;d:ed ascoues ate ray.nrrd to DMr,tle e!1 aJp!!cants me uannrwn<q m rrcmdc slu.j of o° My Commission Expires <br /> rdurmdtmn sy enswe me acwrbeY df the CONr reyvest process All CORf request farms that m-11-field are sfyh. y,�0 <br /> �tegmredly besubmibedla the 001 via man ut byfaatu1617)660-4616. I Dec 14,2023 <br />