Laserfiche WebLink
i <br /> I <br /> -APPLICATION FOB ALCOHOLIC BEVERAGE LICENSE SE The Commonwealth of Massachusetts <br /> Gene.ral questions to be answered by all applicants. <br /> LCC�I OLIC V . AG CONTROL IIICI <br /> Please type or print legibly in int. Fee <br /> I. Type of alcoholic beverages license: (check only ONE) <br /> Restaurant []Restaurant.-, .ammerci'ai.. .lab ElInnholi'der _General On Premises []-tavern []Club <br /> 2P-ackage Goods Store Laj th.er(.specify): <br /> 2. Class of license: fX7AII Alcoholic Beverages <br /> W*ne and Malt Beverages <br /> ja <br /> 3. Applicant is an Individual Partnership D Limited Partnership Business Corporation <br /> i <br /> E -- kion-profit Corporation Other (specify). <br /> r . if applicant is an individual, partnership. general partnership or 11mited partnership, state the following in a, b,and c: <br /> r , <br /> a. For each person FULL NAME HOMEA00RESS SOCIAL SEQU01TY <br /> i <br /> { �b. Firm or trade name, address and telephone no: <br /> C. Business name (d/b/a) if different: <br /> Address: Telephone no: <br /> If appIi cant has a d/b/a. applicant must, include a copy of tine certifi.cate of doing business, required under Mas achusetxs General <br /> Law Chap I 10, Sect, 5, regard Iess of which name w i I I appear on the iicernse) <br /> -..if applicant is a corporation: <br /> a. List the.titles of all officers, the marnage r, and al members of the board directors. Below these list all stockholders <br /> defined in the instruction sheet). Then give the full name, home address and'the number of shares of stock for each <br /> NO.OF SHARES OF <br /> -.TITLE FULL NAMlIE _ .. - _...HO E AOORESS .--. SOCIAL SECURITY STOCK OWNED OR <br /> 52% 1 eU>,1.8n .. <br /> ep nc4 A A A-7 001kZ&,AC a*.,,I 61 L-V6 UPI 5 <br /> CA. &se _j 1 —.0 1 <br /> d <br /> 41,1 <br /> C Aes Ar Z <br /> b. Corporation name; <br /> Address ele <br /> 'A rh4 1-4 A VLd A Telephone no, <br /> c. Business name ( ba) if different: C r CP ry) <f <br /> Address Telephone no.y -. a yal <br /> {If applicant has a d b a*.applicant must include a copy of the certificate of doing business required under Massachusetts <br /> General Law Chap. 1 10. Sect, S. regardless of which name Y4 11 appear on the license) <br /> F <br /> H BBS a WARSEN, INC. FOSS gas - 198.3 <br />