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Coanmonwealth of Massachusetts <br /> alcoholic Beverages Control Coin_tnission <br /> Caasseway Street,Past Floor <br /> - - Boston,MA 02114 <br /> srrr r;v cRttss r-frr r im&G,41,VSBv 0,I q. <br /> r•Rr:.asf,'xr ra-TXD REX-Eff"PR 6f7Vf RRaL CID RI R.EQ1.1F-45 EQ9M�i CHAIRA4- <br /> the AlcOhN;t•iict-:;M_;40('t7ilrrol Corwr:t`:sior,h:w;t>cct1 h}'Lfi,C°rii+±lnui I Iihtor) nourd zo ac-,e!csconvico(wi wid rkxSdiii;+l rirninoi C.)R—rodei Racord <br /> 111*b'maion,I'i4 the rporpose ol'a pprovtng C Ch,l,Ilarchoidcl,I)"vcr,tiCCt:SCc nr 1(ppl:CLIM itli MI alfthobc N:,.V{A_Gt titai H.rimmu t rczord i+hcct. <br /> % ti's he oonducteJ on nit,pulsuanl w Lhe.Abtwc.Tilt i%:Imv k; orrevt to tbL i'tz:f of.tm 4,nt:arlct w <br /> ASCC LICENSE INFORMATION <br /> { # <br /> lt9t:C MItMSE)#: I LICENSEE NAME: 9 4Ste4 LLL 1 CfTY/•ff}4VNk <br /> F3 , <br /> ARPUCANT IAWORA4AVON <br /> LAST NAM : f at'�2 - -- FIRST NAME: GUGdIUe � MIDDLE NAME!}Malone <br /> �v _� L-_____.___._.__._-__] _ . <br /> 1 MAIDEN NAME Oft ALIAS(IF AP1 LICABLEl; n/3 PLACE OF BIRTH: rl8rnphi5,TN <br /> T- --f tD THwr'T INDEX Pb4 fF APPL 1CABLE). —� <br /> f}q.E OF BIRTH: i SS�t: R <br /> }MOTHER'S MAIDEN NAME: DMVEWS LICENSE 9: 1 J� STATE!IC,ISSUcil: ��13tiC'SSZ G' <br /> ( WNGHT: '9S "YE C3LOR: Blue 4 <br /> �C-,ErJs"`,"-.R: MALE HEIGHT' I� ts 11 _._..�E <br /> ! <br /> i CURRENT ADDRESS. f <br /> 0TY1TDirti114: tt::aSftVitke STATE: T>`f_..., � 7tP: �i2t74 <br /> FORMER Af CRESS: <br /> IJTDYVtJ: (Frank.klt STATE: 7iv ZIP: 3'?GfiG <br /> PRINT AND SIGN — <br /> J rrt E <br /> (PRMTFD NAME: Gov'Ciioe M.Parlee ^1 APPUC.4NT/F.MPLa`YEF.SIGNATURE. <br /> t NUTAt4YlPilFt>t2MAT1f11V —. <br /> I' <br /> On this 7*, :2,b 19 before me,the undersigned notary public,personally appei?.red Czcrodl02 M.Puttee <br /> 1 --__.._....__.__.. <br /> (name of document signer),proved to me=hrot,g4z sat;sfactory vidence of iaentiflcation,vrhic#t vn erQ {RSSY�'Et� � � <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. II <br /> I,. ; <br /> �uTfiTE <br /> TENNESSEF. = <br /> NOTARY <br /> PUBLIC <br /> ,,:I s*NUSE0"NILY .2 . <br /> �•,;•;..�.. �`_`�_ Srra.+..�tfr�.;'.S:? ;i,r;AEr:+:Li;l!.i;^r.'"scElK <br /> ;n4c+'isi KN^L': '•tY:(.puCvtt<'C: �c aTixidc, .: r a a ar^+R <br /> :i 1hi,AG;.',.•+un;hen.krve " 'u ptw.•;c <br /> C6ACx+{.ti4S ell i:,0.n`�✓`ttx L(fk: utxst IOrm>il,.!intt+t!.•`�::4�1141d rq� <br /> (Poy+.lroCmCk�uM+li.,eri4:Ste p{;1 iiu mslt urtryhx i;l6.7J WJS-34t. <br />