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5. AMENDMENT-Change of Manager <br /> Change of License Manager <br /> A. MANAGER INFORMATION <br /> The individual that has been appointed to manage and control the licensed business and premises. <br /> Proposed Manager Name SCOTT MULLEN Date of Birth SShI <br /> S <br /> Residential Address <br /> Email SMULLEN@NEWSEABURY.COM Phone 508-539-2216 <br /> Please indicate how many hours per week <br /> you intend to be on the licensed premises 50 Last-Approved License Manager PEDRO T GONZALEZ <br /> B.CITIZENS HIPIBACKGROUND INFORMATION <br /> Are you a U.S.Citizen?* Yes {`':No *Manager must be a U,S.Citizen <br /> If yes,attach one of the following as proof of citizenship US Passport,Voter's Certificate,Birth Certificate or Naturalization Papers. <br /> Have you ever been convicted of a state,federal,or military crime? <br /> j yes Nv <br /> If yes,fill out the table below and attach an affidavit providing the details of any and all convictions.Attach additional pages,if necessary, <br /> utilizing the format below. <br /> Date Municipality Charge Disposition <br /> C. EMPLOYMENT INFORMATION <br /> Please provide your employment history.Attach additional pages,if necessary, utilizing the format below. <br /> Start Date End Date Position Employer Supervisor Name <br /> 03/2017 PRESENT FOOD&BEVERAGE MGR NEW SEABURY RESOURCES MGMT,INC CHRISTOPHER D,CARD <br /> 01/2016 10/2016 GENERAL MANAGER VISCARIELLO HOSPITALITY GROUP SAMMY VISCARIELLO <br /> 1999 2015 OWNER PRESCOTT BROKERAGE SERVICES MARYBETH PRESCOTT <br /> 1983 1999 GENERAL MANAGER BOSTON RESTAURANTS ASSOCIATION WILLIAM BARETTE <br /> D.PRIOR DISCIPLINARY ACTION <br /> Have you held a beneficial or financial interest in,or been the manager of,a license to sell alcoholic beverages that was subject to <br /> disciplinary action? Yes N❑ If yes,phase fill out the table.Attach additional pages,if necessary,utilizing the format below. <br /> re <br /> Date of Action Name of License State City Reason for suspension,revocation or cancellation <br /> i hereby swear under the pours and penalties of perjury that the Information i have provided In this application is true and accurate; <br /> Manager's Signature '" Date <br />