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Commonwealth of Massachusetts <br /> Alcoholic.Beverages Control Commission <br /> 239 Causeway Street,.First Floor <br /> .B os ton,MA.02114 <br /> CORI REQUEST FORM <br /> I <br /> DEBOR"$.GOLROBERG JEANM;LORI IO,ESQ. <br /> TREASURER AND RECEIVER GENERAL CHAIRMAN' <br /> The Alcoholic Beverages Control Commission ("ABCC") has been certified by the Criminal History Systems Board to access <br /> conviction and pending Criminal Offender Record Information("CORI"). For the purpose of approving each shareholder, owner, <br /> licensee or applicant for an alcoholic beverages license,I understand that a criminal record check will be conducted on me,pursuant <br /> to the above.The information below is correct to the best of my knowledge. <br /> ABCC LICENSE INFORMA TION <br /> A6CC NUMBER. LICENSEE NAME:Aeofendw� - p,,G �`�' � �. CITY/TowN: fi /J + <br /> (IF EXISTING LICENSEQ la�P000 9 11 <br /> A PPL I CA N T INF O RMA TION <br /> LAST NAME: Mellen FIRST NAME: Scott MIDDLE NAME: Andrew <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OF BIRTH: <br /> DATE OF BIRTH: SSN: ID THEFT INDEX PIN(IF APPLICABLE): <br /> i <br /> MOTHER'S MAIDEN NAME: DRIVER'S LICENSE#: STATE LIC.ISSUED: Massachusetts <br /> GENDER: MALE HEIGHT, WEIGHT: EYE COLOR: Brown <br /> CURRENT ADDRESS: <br /> CITY/TOWN: STATE:, ZIP: <br /> FORMER ADDRESS: <br /> CITY/TOWN: STATE: ZIP: <br /> PRINTAND SIGN <br /> PRINTED NAME: �� LV- APPLICANT/EMPLOYEE SIGNATU RE: , <br /> NOTARYINFQRMATION <br /> On this ' r. before me,the undersigned notary public,personally appearedllel"Al <br /> name of document signer),proved to me through satisfactory evidence of identification,which were {, <br /> to be the person whose name is signed an the preceding or attached document,and acknowledged to me that(he)(she)si ned it voluntarily for <br /> its stated purpose. <br /> NOTARY <br /> T"RA%ANcENT JOya <br /> NOTARY PUBLIC <br /> * Crmmonweallh o massachuse"t <br /> DIVISION LISE ONLY any (:Om mission Expires <br /> Marra 5, 2021 <br /> REQUESTED]BY: <br /> 31=7 in?D C - —0—R !]EMPLOYEE <br /> The D Q1 Identify Theft Index PIN Number is to be completed by those applicants that have been Issued an Identity Thett; <br /> PIN Number by the D}Gi.Certified agencies are required to provide all applicants the opportunity to Include ihis <br /> Information to ensure the accuracy of the CORI request protest,ALL CORI request forms that include this field are <br /> required to be submitted to the DCII via mail or by faxto(617166041614. <br />