Laserfiche WebLink
Commonwealth of Massachusetts <br /> m. <br /> Alcoholic Beverages Control Commission <br /> 239 Causeway Street,First Floor <br /> r M <br /> Boston,MA.02114 <br /> CORI UQUEST FMLEBORAHB.GOLBDBERs JEAN .L ORIZ10,E'`S►Q. <br /> TREASURER AAD RECEIVER GENERAL CHAIRMAN <br /> The Alcoholic Beverages Control Commission ("A BCC") has been certified by the Criminal History Systems Board to access <br /> conviction and pending Criminal Offender Record Information ("CORI"). For the purpose of approving each shareholder, owner, <br /> licensee or applicant for an alcoholic beverages license,I understand that a criminal record check will be conducted on me,pursuant <br /> to the above.The information below is correct to the best of mar knowledge. <br /> ARC'C'LICENSE INFORMATION <br /> ABCC NUMBER: LICENSEE NAME: �''�, �� �G�" A �i 'w' ' , , '" CITY/TOWN: <br /> ct E3li571P+ICa ucls� '" <br /> A PPL1C A NT INFORMA T1ON <br /> 000 <br /> LAST NAME. Mullen . <br /> FIRST INAIVIE. Scott MIDDLE NAME: Andrew <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OF BIRTH: Boston,MA <br /> DATE OF BIRTH: SSN: ID THEFT INDEX PIN(IF APPLICABLE): <br /> .. ..................................................................................... <br /> MOTHER'S MAIDEN NAME; DRIVER'S LICENSE##: STATE LCC.ISSUED: <br /> Massachusetts <br /> I ,o »nnn��«« <br /> GENDER: MALE HEIGHT: 6 2 WEIGHT; 255 EYE COLOR: [Brown <br /> CURRENTADDRESS: . <br /> M <br /> CITY/TOWN; Centervlile STATE: MA ZIP: 02632 <br /> .......... <br /> FORMER ADDRESS: k <br /> m <br /> CITY/TOWN: Braintree STATE; `MA ZIP: 02184 <br /> PRtNTAND S►GN <br /> II <br /> PRINTED NAME: t, L2V1APPLICANT/EMPLOYEESIGNATURE: <br /> Ij <br /> NOTARYINFORMATION <br /> On this � �- { before me,the undersigned notary public,personally appeared �rt <br /> (name of document signer),proved to me through satisfactory evidence of identification,which were <br /> T <br /> to be the person whose name is signed on the preceding or attached document,and acknowledged to me that(he)(she)simed it voluntarily for <br /> its stated purpose. <br /> m, <br /> NOTARY <br /> MM )ANCEW Y <br /> its NOTARY PUBLIC <br /> ,DI ION U 5EONLY " My Co,mmisston xp,r" <br /> , <br /> oo <br /> March 2021 <br /> REQUESTED BY: <br /> ri ry r r�dre6 i- 1 6rA WTKL&F <br /> The DCJi Identify Theft index PIN Number is to be completed by those applicants that have been Issued an Identity Theft <br /> PIN Number by the DC,l1.Certified agencies are required to provide all applicants the opportunity to Include this <br /> Information to ensure the,accuracy of the CORI request process. ALL CORI request forms that Include this field are <br /> required to be submitted to the DCil aria mail or by fax to(617)6E0--MI& <br />