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f Commonwealth o,f Massachusetts <br /> .Alcoholic Beverages Control Commission <br /> 239 Causeway Street,First Floor <br /> Boston,MA 02114 <br /> C""N 0 0) <br /> CORI RE CJ�.S T F OR11� <br /> DEBORAH B.GOLBDBERG JEANK LDRIZIG,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 INFORMATION <br /> ABCC NUMBER: ;: LICENSEE NAME, _ ,`� f �'� '• ��' ITY/TDUVN: � <br /> (IF IxisntG LICENSE <br /> APPLICANT INFORMATION <br /> LAST NAME: Mullen FIRST NAME: Scott MIDDLE NAME: Andrew <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OF BIRTH: I. <br /> DATE OF BIRTH: SSN: ID THEFT INDEX PIN(IF APPLICABLE): <br /> MOTHER'S MAIDEN NAME: DRIVER'S LICENSE#: STATE LIC,ISSUED: Massachusetts <br /> GANDER: MALE HEIGHT: WEIGHT: EYE COLOR: grown <br /> CURRENT ADDRESS: ' <br /> CITY/TOWN: t STATE: ZI P: <br /> i <br /> FORMER ADDRESS: <br /> CITY/TOWN: STATE: ZIP. ". <br /> PRINTAND SIGN <br /> PRINTED NAME: ,, ' APPLICANT/EM PLOY EE 51GNATURE: Lq �-,61�a <br /> ti <br /> NOTARYINFaRMATION <br /> On this 1, before me the undersigned rota public,personally a eared � •IleI <br /> g notary p ►p y pP <br /> (name of document signer),proved to me through satisfactory evidence of identification,which were <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. <br /> NOTARY <br /> TAMARA► VINCENT JOYCE <br /> NOTARY PUBLIC <br /> Commonwealth of Massachusetts <br /> DIVISION USE ONLY My Kilo ipiss o nE'spires <br /> I <br /> REQUES IED BY! <br /> 3IG T R o COfll A o P O E <br /> The DCII identify Theft Index PIN Number Is to be completed by those applicants that have been Issued an Identity Theft <br /> PIN Number by the pal.certified agencies are required to provide ail applicants the opportunity to include this <br /> Information to ensure the accuracy of the coo request procass, ALL CORI request forms that Include this field are <br /> required to be submitted to the poi via mall orbyfax to t617f 669-4614, <br />