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5. AMENDMENT-Chan a 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 SSN <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 54 Last-Approved License Manager PEDRO T GCNZALEZ <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? Yes C:No <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 /> t <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 1 B12016 GENERAL MANAGER- VISCARIELLO HOSPITALITY GROUP SAMMY VISCARIELLO <br /> 1999 2015 OWNER PRESCOTT BROKERAGE SERVICES MARYBETH PRESC07T <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? �; If yes,please fill out the table.Attach additional pages,if necessary,utilizing the format below. <br /> C.Yes �'`No <br /> Date of Action Name of License State City Reason for suspension,revocation or cancellation <br /> S <br /> i <br /> 1 hereby swear under the pains and penalties of perjury that the information I have provided In this application Is true and accurate: <br /> Manager's Signature Date =10 <br /> 7 <br />