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APPLICATION FOR AMENDMENT-Change of Officers. Stock or Ownership Interest <br /> 2. PROPOSED OFFICERS, STOCK OR OWNERSHIP INTEREST <br /> List all individuals or entities that will have a direct or indirect,beneficial or financial interest in this license(E.g.Stockholders,Officers, <br /> Directors,LLC Managers,LLP Partners,Trustees etc.).Attach additional page(s)provided,if necessary,utilizing Addendum A. <br /> • The individuals and titles listed in this section must be identical to those filed with the Massachusetts Secretary of State. <br /> • The individuals identified in this section,as well as the proposed Manager of Record,must complete a CORI Release Form. <br /> • Please note the following statutory requirements for Directors and LLC Managers: <br /> On Premises(E.g.Restaurant/Club/Hotel)Directors or LLC Managers -At least 50%must be US citizens; <br /> Off Premises(Liquor Store)Directors or LLC Managers -All must be US citizens and a majority must be <br /> Massachusetts residents. <br /> • If you area Multi-Tiered Organization,please attach a flowchart identifying each corporate interest and the individual owners of <br /> each entity as well as the Articles of Organization for each corporate entity. Every individual must be identified in Addendum A. <br /> Name of Principal Residential Address SSN DOB <br /> Farles 0.Noyes <br /> Title and or Position _ Percenta e of Owners hi Director/LLC Manager US Citizen MA Resident <br /> FLLC—Manager,President 100/. No (:)Yes C)No ( Yes (-N� <br /> Name of Principal _ Residential Address SSN DOB <br /> Kurt Schnaubelt F <br /> � —� <br /> � � <br /> Title and or Position Percentage of Ownershi Director/LLC Manager US Citizen MA Resident <br /> Ec:manager,CFO 0% �� �� <br /> { Yes {"`No ( Yes C)No (",Yes f :No <br /> Name of Principal _ Residential Address SSN DOB <br /> Foodloe M.Partee <br /> Title and or Position Percentage of Owners hi Director/LLC Manager US Citizen MA Resident <br /> LLC Manager,General Counsel,Secretary 0% <br /> _ ( Yes C No { ;Yes �" No ( Yes • No <br /> Name of Principal _ Residential Address SSN DOB <br /> W.Craig Barber � � [ I <br /> Title and or Position Percentage of Ownershi Director/LLC Manager US Citizen MA Resident <br /> LLC Manager,CEO �0% { Yes ('I No I] (' Yes ('s No Yes ( :No <br /> Name of Principal Residential Address SSN DOB <br /> [99 Restaurants,LLC I <br /> Title and or Position Percentage of Ownershi Director/LLC Manager US Citizen MA Resident <br /> LLC Member _ 100% Yes (:;No ( Yes ( No C,,Yes (.".No <br /> Name of Principal Residential Address SSN DOB <br /> [See Exhibit A for additional information <br /> Title and or Position Percentage of Ownershi Director/LLC Manager US Citizen MA Resident <br /> (`;Yes (:}No {'`Yes C No (`.Yes (r`No <br /> Additional pages attached? {;; No <br /> CRIMINAL HISTORY <br /> Has any individual listed in question 6,and applicable attachments,ever been convicted of a C"Yes (o No <br /> State,Federal or Military Crime?If yes,attach an affidavit providing the details of any and all convictions. <br /> MANAGEMENT AGREEMENT <br /> Are you requesting approval to utilize a management company through a management agreement? <br /> Please provide a copy of the management agreement. (",i Yes { ;N 22 <br />