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S. AMEN DMENT-Change of Manpgq <br /> Q,mqLg_cif icense Man.aggir <br /> ............. <br /> ,A. IIA NACU ER INFORMATION <br /> The individual that has been appointed to manage and control the licensed business and premises. <br /> Proposed Manager Name�.SCOT"MULLEN Date of Birth SN <br /> Residential Address <br /> .............. <br /> Email SMULLEN@NEWSEABURY.COM Phone <br /> mmmmmmmmmm <br /> ........... <br /> Please indicate how many hours per week [5E] <br /> you 50 <br /> �L <br /> in you intend to be on the licensed premises Last-Approved License Manager [PE <br /> LET <br /> B.CITIZENSHIP/BACKGROUND INFORMATION <br /> ............ <br /> Are you a U.S.Citizen?* Yes No *Manager must be a U.S.Citizen <br /> If yes,attach one of the following as proof of citizenship -US Passport,Voter's Certificate,Birth Certificate or Naturalization Papers. <br /> Have you ever been convicted of a state,federal,or military crime? Yes No <br /> If yes,fill out the table below and attach an affidavit providing the details of any and all convictions.Attach additional pages,if necessary, <br /> utilizing the format below. <br /> Date Municipality Charge Disposition <br /> ............ ....... J <br /> C. EMPLOYMENT INFORMATION <br /> Please provide your employment history.Attach additional pages, if necessary, utilizing the format below. <br /> ................. <br /> Start Date End Date Postion Employer Supervisor Name <br /> ........................ <br /> i <br /> ----—---------- ........................... <br /> 03/2017 PRESENT FOOD&BEVERAGE MGR NEW SEABURY RESOURCES MGMT,INC CHRISTOPHER D.CARD <br /> I-111 ­­­­­­­l _.. ... ........ .................""_ ....... <br /> 01/2016 10/2016 "GENERAL MANAGER VISCARIELLO HOSPITALITY GROUP SAMMY VISCARIELLO <br /> ......................mmmmmmmm <br /> .. <br /> 1999 2015 OWNER PRESCOTT BROKERAGE SERVICES MARYBETH PRESCOTr <br /> 1983 1999 GENERAL MANAGER BOSTOOSTON RESTAURANTS ASSOCIATION WILLIAM BARETTE <br /> -—------------- <br /> 'D.PRIOR DISCIPLINARY ACTION <br /> .................................. ......................- - <br /> Have you held a beneficial or financial interest in,or been the manager of,a license to sell alcoholic beverages that was subject to <br /> disciplinary action? ( Yes No If yes,please fill out the table.Attach additional pages,if'necessaryutilizing the format below. <br /> Date of Action Name of License State City Reason f6 r......................s....................u..........._s­p­ension,revoca-'tion or cancellation <br /> ........ ------ <br /> I hereby swear under the pains and penalties of perjury that the information have provided in this application-is...............t rue and accurate: <br /> Vanager's Signature Date <br /> =qC) <br /> 7 <br />