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t <br /> ' - - <br /> I . If applicant will be leasing the premises to.be licensed, state: <br /> a. b, Beg inning <br /> date-of leases Ending date of lease <br /> � per 1. <br /> __VM 4W N I M4 y A K I�,J <br /> •� �� 19. 7 . _ a <br /> 13. a. State the names, addresses, and telephone numbers.of al persons-or entities w ho will harre any direct or indirect <br /> beneficial or finalncial: interest in thi s,4 i cen se, as re qu1red by Iwlassachusetts General Lave c. 138, s. I A; <br /> NAME Apes ULEPHONE NumaeR <br /> MaLoo <br /> 6r <br /> b. Describe all types of financial and beneficial interest each person or entity-will I have in this Iieense: <br /> _ w n. i uM rwa.i—r...r.r.r�rtra•.n.n�•nr�r ■n+r-- w�Y.wr�r�rrr�i��.�iww+f <br /> 14. a. Does any person or entity listed in question 13 have any direct or indirect beneficial or financial interest in any other <br /> type of license granted under plass. General Law 138? <br /> RTY esNAmIE4 g N o b. If yes, saoe for each eson or entir. <br /> DDRESS � SE., RIPTION OF INTEREST <br /> I .R a. a any person or entity named in question 1 ewer held a license underG.L.c, 13 which he she it does not presently hold? <br /> Yes No b. If yes, state for each: <br /> NAME TYPE OF LICENSE LI EN E ADORF-SS DATE LICENSE GRANTED <br /> 16.. a. Has any person or entity named in question 13 ewer had his/her/its license revoked or cancelled? Yes <br /> 9 . 9 0 <br /> b. If yes, state for each name the date and reasons why the license was revoked or cancelled: <br /> 17. Has any person or entity named in question 13 ewer been convicted of violating any state or federal law? exclude minor <br /> craffic violations) Yes 2fio If yes, attach a statement of details, <br /> 18. If applicant is an individual. answer Vie-following questions: <br /> a. Are your a United States Citizen? []Yes []No h. Are you at least twenty years old? []Yes [] o <br /> (If fires provide a Capt' of birth, natgrali aktion or registered votercertificate) <br /> 19. If applicant is a partnership, answer the following questions: <br /> a. Are al l the partners United States Citi zeas? 11 Yes 11 No b, Are al of the partners at least twenty years old? 0 Yes No <br /> Provide copies of birth, naturalization or registered voEer Certificates for each partner) <br />