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11C. PREVIOUSLY HELD INTEREST IN AN ALCOHOLIC BEVERAGES LICENSE <br /> Hasany individual or entity identified in question 11 A,and applicable attachments,ever held a director indirect,beneficial or <br /> financial interest in a license to sell alcoholic beverages,which is not presently held? <br /> Yes r7 No if yes,list in table below.Attach additional pages,if necessary,utilizing the table format below. <br /> It <br /> Name License Type License Name Municipality <br /> ----------- <br /> 11D* PREVIOU"'SLY HELD MANAGEMENT AGREEMENT <br /> Has any individual or entity.identified in question 11 A,and applicable attachments,ever held a manager ent agreement with any <br /> other Massachusetts licensee? <br /> Yes No If yes,list in table below.Attach additional pages,if necessary,utilizing the table format below. <br /> ............... <br /> Licensee Marne ...................... License Type Municipality Date(s)of Agreemen�t <br /> ........................ <br /> ---——--------------- <br /> 11E. DISCLOSURE OF LICENSE DISCIPLINARY ACTION <br /> Has an—yo `—thedisclosecl licenses listed in questions in section 11131 11 C, 11 D ever been suspended,revoked or cancelled? <br /> Yes 7 No F7 If yes,list in table below.Attach additional pages,if necessary,utilizing the table format below. <br /> Date of Action Name of License city 'Reason for suspension,,revocation or cancellation <br /> ........... ...... <br /> ....................... ...... ............ ............... <br /> ............. <br /> ................... ....... <br /> 11F. TERMS OF AGREEMENT <br /> a.Does the agreement provide for termination by the licensee? Yes r7 No <br /> b.Will the licensee retain control of the business finances? Yes No [7 <br /> C.Does the management entity handle the payroll for the business? Yes No <br /> d.Management Term Begin Date e.Management Term End Date 1 7 <br /> f.How will the management company be compensated by the licensee?(check all that apply) <br /> F� $per month/year(indicate amount) ................................. <br /> E. ............... ...................................... <br /> %of alcohol sales(indicate percentage) <br /> %of overall sales(indicate percentage) <br /> other(please explain) .... .... ......................... <br /> ABCC Licensee Offlicer/LLC Manager Management Agreement Entity Officer/LLC Manager <br /> . <br /> Signature:L.................. ... titi I................................................. <br /> Signature:........ .... . <br /> .............. <br /> Title: Title: <br /> .......... ...................... ..... <br /> Date: Date: <br />