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.... .................. ....... ................... APPLICATION FOR ANEW LICENSE <br /> .......... <br /> CORPORATE STRUCTURE ........... <br /> .................... <br /> 9/7/2016�� <br /> Corporation Date of Incorporation <br /> ......... <br /> .......... ................ ......................... ............... ......... 97 <br /> Entity Legal Structure <br /> State of Incorporation 7 <br /> Massachusetts Is the corporation publicly traded? Yes No <br /> ........... ..............""!........... <br /> ........... ................ <br /> 6. PROPOSED OFFICERS, <br /> ........... 1,111115TOCK OR OWNERSHIP INTEREST <br /> List all individuals or entities that will have a director indirect, beneficial or financial interest in this license(E.g.Stockholders,Officers, <br /> Directors,LLC Managers,LLP Partners,Trustees etc.).Attach additional page(s)provided,if necessary,utilizing Addendum A. <br /> • The individuals and titles listed in this section must be identical to those filed with the Massachusetts Secretary of State. <br /> • The individuals identified in this section,as well as the proposed Manager of Record,must complete a CORI Release Form. <br /> Please note the following statutory requirements for Directors and LLC Managers: <br /> On Premises(E.g,Restaurant/Club/Hotel)Directors or LLC Managers -At least 50%must be US citizens; <br /> Off Premises(Liquor Store)Directors or LLC Managers -All must be US citizens and a majority must be <br /> Massachusetts residents. <br /> If you are a Multi-Tiered Organization,please attach a 'flow chart identifying each corporate interest and the individual owners of <br /> each entity as well as the Articles of Organization for each corporate entity. Every individual must be identified in Addendum A. <br /> N a,Te of Principal .......... Residential Address SSN DOR <br /> Lp­............. ........................................................... ................ ................................... <br /> �� hl �►Ji� in�or 02053 <br /> Title and or Position Perctqt�jqq of Ownership 'Director/LLC!Manager US Citizen MA Resident <br /> E" .......... <br /> President ................................11 <br /> Yes <br /> 'Yes ( No Yes No <br /> 0 <br /> Name of Principal R�rr�__nnnnn��n.n�« <br /> esidential Address SSN DOB <br /> (A 02053 <br /> Tracey Wilkinson <br /> .......... ...........__ji <br /> .... . <br /> Posit <br /> Title and or ion Per, e of Ownership, Director/LLC Manager US Citizen NIA Resident <br /> Vice President 150 7�_ ............... <br /> ( Yes ( No <br /> Yes No <br /> Name of Principal Residential Address <br /> SSN DOB <br /> ...........awawam <br /> . <br /> ................ .................. .......... <br /> .................... ....... <br /> Title and or Position Percenta�Lq of Ownershir Director/LLC Manager US Citizen MA Resident <br /> ........... .......... Yes No Yes No "`Yes (7 No <br /> Name of Principal Residential Address SSN, DOB <br /> ................ <br /> ........... ..................... .......... <br /> ,nnnnnnnL <br /> Title and or Position. .mm'Per qentaq, f Ownersh!f� Director/LLC Manager US Citizen MA Resident <br /> Yes Yes No <br /> ............. ..............................................................——------.......——---- 1 C Yes No ( Yes <br /> .......................................................... ............. _J <br /> Name of Principal Residential Address SSN DOB <br /> ............................................................................ ............................ <br /> ............ .................. <br /> Title and or Position ---"""""-,.".,l-.,Percent�rje of Ownersh!,�-,) Director/LLC Manager US Citizen MA Resident <br /> ...................... <br /> .................................... ......... Yes C No Yes No Yes No <br /> : <br /> ................. <br /> —------------ ....... <br /> Additional pages attached? Yes • No <br /> CRIMINAL HISTORY <br /> Has any individual listed in question 6,and applicable attachments,ever been convicted of a Yes No <br /> State,Federal or Military Crime.?If yes,attach an affidavit providing the details of any and all convictions, <br /> 2 <br />