Laserfiche WebLink
Commonwealth of Massachusetts <br /> Alcoholic Beverages Control Commission <br /> 239 Causeway Street,First Floor <br /> Boston,MA 02114 <br /> KIM GAINSBORO.E-qQ. <br /> STErEN GROSSN[AN TIZEASUREN AND REMI'ER GEIN'EK"L C.0R1 REQUEST FORM CHAI)WAN <br /> ct'wmt Commigirsti lilts horn certified by the Crimial I I i.qory S'..stcrris Board to access cx)nyjaiji)n and pendIng Ctiminat Ofiender Record <br /> i al record check <br /> crimin <br /> n cacti s rot an alctiholle heverages license, n c n <br /> , rrriatt�lyj I:(),,lilt puyllsenfailprovirtL <br /> will tic con-ducted on mc-.PLOUaIll 1.0 the 4brive 'I'ho infortnalmn helm~is corlitel to the hest oi'my knowledge <br /> AMCC LICENSE WFORMAMN <br /> ABCCNUMBFR,, 1 99 West,LLC <br /> LICENSEE NAME* CiTY/TOWN., <br /> F- JJJ <br /> APPLICANTINFOPMATICIN <br /> LAST NAME: Barter FIRST NAME: El�ltt- MIDDLE NAME' Craig <br /> Nashville,MAIDEN NAME OR ALIAS{if APPLICABLE}: barber PLACE OF BIRTH,. F <br /> Fvu.-t_ <br /> DATE OF BIRTH SSN: F ID THEFT INDEX PIN(If APPLICABLE): f <br /> MOTHER'S MAIDEN I NAMES DRIVER'S LICENSE P: STATE LICJSSUED: FT:en:ne�5see <br /> WEIGHT: EYE COLOR., F. Z-I <br /> GENDER:FMALE HEJGHT: <br /> CURRENT ADDRESS: <br /> L <br /> CITY/TOWN; Nashville I STATE:[IN== ZIP: j37215 <br /> FORMER ADDRESS. <br /> .......—----- <br /> CLTYITOWN: STATE: ZIP: <br /> 471"Wria jut)VrIN <br /> PRINTED NAME: .F Craig Barber i APPLICANT/EMPLOYEE SIGNATURE. <br /> OTARY04FORMATION <br /> On this before me,the undersigned notary public,personally appeared W.Craig Barber <br /> i(na-me of document sjg7-er),proved to me through satisfactory evidence of identification,which were <br /> to 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 /> its stated purpose. <br /> NOTARY <br /> x P <br /> • TAT-S.M <br /> OF <br /> TEI.,94ESSEE <br /> 7 <br /> PUBLIC 4 <br /> Divi.SOMWN U 's <br /> C a vi� <br /> o'4:m P—..AIC MAI�1 i—Wiw i.l—4ss liM me <br />