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,6. AMENDMENT-Change fficeronn�,,,,,,,,.5,tock or Owner j.......... sh_pJ 'erest
<br /> khan a f Ownephip"I,n terest
<br /> . J.............
<br /> ng,e of Stock New Stockholder/
<br /> ....................................................
<br /> JK _J.��tg
<br /> "ne of Officers/Directors
<br /> ..................... (LLC Mana ers/LLP Partner Trustees Transfer or Issuance of Stock
<br /> ........................1111_1111 .................. ll",, -1)
<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 /> I
<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 area Multi-Tiered Organization,please attach a flowchart 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 /> Name of Principal Residential Address SSN DOB
<br /> ................................ ...................... ..................
<br /> HRISTOPHER D CARD
<br /> Title and or Pos itio n ——----------
<br /> _Percenta�&of Ownershi,,,, Director/LLC Manager US Citizen M.A.Resident
<br /> RESIDENT/DIRECTOR..................... .........--- ---- ........... .......... ...............
<br /> Yes No Yes No Voc No
<br /> 10-0/0 .........._`
<br /> Name of Principal Residential Address SSN
<br /> ............ --—---- DOB
<br /> . .............
<br /> �LORRAINE J.COFFEY ........................................................................ ....... ...................
<br /> A ........... ...................................................................
<br /> Title and or Position Perce e of Owners hi Director/LLC Manager US Citizen
<br /> ........ MA Resident
<br /> .................
<br /> Yes e (*'Yes No C-* Yes No
<br /> ...................
<br /> SECRETARY/LICE PRESIDENT 0%
<br /> ..... -----
<br /> I'll — 1i 111�1111111111111��.. .................................
<br /> Name of Principal Residential Address SSN DOB
<br /> ........... ..............................................................................
<br /> SUE HOOVER
<br /> ................
<br /> Title and or Position Jercenta�e of Ownershh) Director/LLC Manager US Citizen MA Resident
<br /> ..........................................................................
<br /> ..........._._ 7.. ..........................
<br /> 1,TEASURER/VICE PRESIDENT 0% (*' Yes ( No I (*'Yes ( No
<br /> ............................................. ..........
<br /> ............ ..... I _-J .......................................
<br /> Name of Principal Residential Address SSN
<br /> ... DOB
<br /> ...................................................................... ............................ ..................................
<br /> ....... ................................................... .. .............................................
<br /> Title and or Position Percentaq,a of Ownershjp, Director/LLC Manager US Citizen..................
<br /> MA Resident
<br /> ........................................................
<br /> ............. .........
<br /> ........... .................. s ( No ( Yes ( No Ye
<br /> mmm
<br /> ................
<br /> ................................
<br /> Name of Principal Residential Address SSN DOB
<br /> ......._ ........................ ........................................... ........... ....
<br /> E . ................. ...............
<br /> Title and or Position Per................... ,",,,qgnjAge of_QWnyy.ershiP Director/LLC Manager US Citizen MA Resident
<br /> ( Yes, C No ...........
<br /> .......... ....... ................. Yes No
<br /> rrrrr
<br /> rrrr
<br /> Name of Principal Residential Address SSN DOB
<br /> ........ ...............
<br /> ..............__���.,,,,......
<br /> ....................................................................
<br /> .................
<br /> Title and Position ......................................... 0 wpn e r�shh i Director/LLC Manager US Citizen MA Resident
<br /> ................ ....................;....................................
<br /> .............. Yes C No Yes No ( Yes ( No
<br /> .......................... ............... ....... ......
<br /> Additional pages attached? Yes No
<br /> CRIMINAL HISTORY
<br /> .................-—----------------
<br /> Has any individual listed in question 6,and applicable attachments,ever been convicted of a
<br /> ...........-
<br /> State,Federal or Military Crime?If yes,attach an affidavit providing the details of any and all convictions. ( Yes (,*'No
<br /> MANAGEMENT AGREEMENT
<br /> _-, 11.........................
<br /> Ai"e—y-66'requesting approval to utilize a management company through a management agreement? ...............
<br /> Please provide a copy of the management agreement. C Yes (ib No
<br /> .............
<br />
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