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6. AMENDMENT-Ch r of Off!' <br /> or Ownershi <br /> ................. p jpteres <br /> Can ge of Ownership[ptere der/ <br /> Chmp of Officer /Directors <br /> + hn _9fStock <br /> LL+ jA", g,ers/LLP Partnerst,Tru-S <br /> ................ _ fte, Transfer orissuance'" of Stock <br /> List all individuals or entities that will have a direct or 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 Prem i ses(Liq u or Store)Directors car LLC Managers -Af I must be US,citizens a n d 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 /> Name of Principal Residential Address <br /> ......................................... ......... SST DOB <br /> r....................... .................... ........... <br /> HRISTOPHER D CARD <br /> ............... .............................................. ..................... ............... <br /> Title and or Position Percenta e of Ownershi) Director/LLC Manager US Citizen <br /> .......... MA Resident <br /> .........- I Yes ( Yes (*'No <br /> LO/O <br /> Eire re No <br /> Name of Principal Residential Addresq SSN DOB <br /> ............................. <br /> ............ ...........................---— .. ..... ....... <br /> .......... .................... <br /> Title and or Position —--—-----------------------"--Pe'rcentagg o Director/LLC Manager US Citizen MA Resident <br /> Ownerllqhi, <br /> SECRETARY/VICE PRESIDENT 011/0 7i( N Yes 0 N <br /> Yes6*% Yes No <br /> Name of Principal Residential Address SSN DOB <br /> .................. ........... <br /> SUE HOOVER <br /> ............ ................. .......... <br /> Title and or Position ................... Perce�n�ac e of Ownershi,".. Director/LLC Manager US Citizen <br /> MA Resident <br /> TREASURER/VICE PRESIDENT 0% 'Yes1 - <br /> --------- ............................... . .......N o Yes- No <br /> Name of Principal Residential Address <br /> ...... SSN DOB <br /> ............... ........... <br /> ................... ............ ........... ......... ............................ <br /> .rvrvrvry <br /> Title and or Position .......................................... Percf��taqe of Ownershin Director/LLC Manager <br /> US Citizen MA Resident <br /> ................... ( Yes ( No Yes No Yes C No <br /> Name of Principal Residential Address SSN DOB <br /> ................................................. <br /> 71 <br /> ............... ...... ...... .........................................................................................——-—"' <br /> Title and or Position <br /> Pe,centAq.Le of Director/LLC Manager US Citizen MA Resident <br /> ..................................... ...................... ........... <br /> ......................... r Yes C No Yes Na C Yes No <br /> Name of Principal Residential Address ........... <br /> SSN DOB <br /> ..................................... ............................. -—------------------ <br /> Title and or Position Percenta e of Ownershk-� Director/LLC Manager US Citizen MA Resident <br /> .............. .................... ............ .. .... ...................__"'....... <br /> ..........--—"-------------------.............................. .......... ("Yes ( No Yes r No ( Yes ( No <br /> .............................. <br /> Additional pages attached? ( Yes, (*'No <br /> ........... <br /> MINAL HISTORY <br /> Has any individual listed in question 6,and applicable attachments,ever been convicted of a Lr Y re No <br /> .es.......... <br /> State,Federal or Military Crime?If yes,attach an affidavit providing the details of any and all convictions. ............... <br /> MANAGEMENT AGREEMENT <br /> Airey­o_—ur e qu—est i n g-a p'p-r-ov'al to utilize a management company through a management agreement? ...................................................... <br /> Please provide a copy of the management agreement. C' Yes 6' No 8 <br />