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APPLICATION F ICENSE <br /> 5. CORPORATE STRUCTURE <br /> Entity Legal'Structure Corporation Date of Incorporation Aug 6,2015 <br /> Incorporation Massachusetts Is the Corporation publicly traded? C Yes (W No <br /> State of <br /> 6. PROPOSED OFFICERS, STOCK OR OWNERSHIP INTEREST <br /> List all individuals or entities that will have a director indirect,beneficial orfinancial 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 /> e The individuals and titles listed in,this section must be identical to those filed with the Massachusetts Secretary of State. <br /> o The individuals identified in this section,as well as,the proposed Manager of Record,must complete a CON I Release Form, <br /> o Please note the following statutory requirements for Directors and LLC Managers: <br /> On Premises(E.g.Restaurant/Club/Hotel)Directors r LLC Managers -At least 50%must be US citizens; <br /> Off Pre mises(Liquor Store)Directors,or LLC Managers, -All must be US citizens and a majority must be <br /> Massachusetts residents. <br /> o 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 /> F_ <br /> hpee MA 02649 <br /> EJan Aggerbeck <br /> Title and or Position Percentage of Ownershj Director/LLC Manager U'S Citizen MA Resident <br /> Director 50 Yes ( No, (a'Yes, C' No (e' Yes C No, <br /> Name of Principal Residential Address SSN DOB <br /> Pamela S Aggerbeck hpee MA 02649 <br /> Title and or Position Percentage of Ownershi Director/LLC Manager US Citizen MA Resident <br /> Director 50 (o' Yes C No Ero Yes C No ('o Yes ( No <br /> Name of Principal Residential Address SSN' DOB <br /> E: <br /> Title and or Position' Percentage of Ownershl Director/LLC Manager US Citizen MA Resident <br /> r Yes No C Yes No ( Yes ( No <br /> Name of Principal Residential Address SS,N DOB <br /> Title and or Position Percentage of Ownership Director/LLC Manager US Citizen MA Resident <br /> Yes C No C Yes C No Yes No <br /> Name of Principal Residential Address SSN DOB <br /> Title and or Position Percentage of Ownershi Director/LLC Manager US Citizen MA Resident <br /> Yes No Yes C No Yes No <br /> Additional pages attached.? Yes (e'No <br /> CRIMINAL HISTORY <br /> Has any individual listed in question ,and applicable attachments,ever been convicted of a C' Yes (W No <br /> State,Federal or Military Crime.?If Yes,attach an,affidavit providing the detai,ls of any and all convictions. <br /> 2 <br />