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Commonwealth of Massachusetts <br /> Alcoholic Beverages Control Comm* sion <br /> �w.U 239 Causeway Street,First Floor <br /> ' S Boston,MA02114 <br /> rcR� : LR CORIREQUES T F' <br /> JEAN M.LORIZ10,ESQ. <br /> TREASURER AND►RECEIVER GENERAL CHAIRMAN <br /> The Alcoholic Beverages Control Commission ("A CC") 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 licensee,I understand that a criminal record cheep will be conducted on ine, pursuant <br /> to the above.The infon nation below is correct to the blest of my knowledge. <br /> ABCC LICENSE INFORMATION <br /> 7ABCC NU "IBER: LICENSEE NA fE. 'ITY/ToINN: � � � <br /> (IF EXISTING LICENSEES � �_ '' �.+ �w <br /> APPcICAnrTI FORMaTIO r <br /> LAST NAME: [Mullen FIRST NAME: 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 /> MOTHER'S MAIDEN NAME: DRIVER'S LICENSE#: u� STATE LIC.ISSUED: Massachusetts <br /> (GENDER: MALE HEIGHT: 6 2 WEIGHT: 255 EYE COLOR: Brown <br /> ,,a mmmm 1 <br /> CURRENT ADDRESS: <br /> CITY/TOWN: 'Centerville STATE:FMA ZIP: 02632 <br /> FORMER ADDRESS: <br /> CITY C7wWN: Braintree <br /> � STATE:[MA ZIP: 02184 <br /> �m� mmm ................................. <br /> mm <br /> PRINT AND SIGN <br /> PRINTED NAME: APPLICANT/EMPLOYEE SIGNATURE: <br /> NOTARY INFCIRMA TION <br /> rvrvrvry <br /> On this <br /> before me,the undersigned notary public,personally appeared <br /> (name of document signer),proved to me through satisfactory evidence of identification,which were <br /> i <br /> ' I , lf�7 <br /> to be the person whose name is signed on the preceding or attached document,and acknowledged to me that(he)(she)signed it voluntarily for <br /> its stated purpose. <br /> ........................ <br /> NOTARY <br /> TA MA `A MCE NT JoycE <br /> * NOTARY PUBLIC <br /> rl�lstl r u ONLY +:amm0r1weea1fh Of Massachus,e'tts <br /> ►y Commission Expires <br /> FREQUESTEDBY: VOK March 5.. 2021 <br /> The VCJI Identify Theft Index PIN Number Is to be completed by those applIcents that have been issued are identity Theft <br /> PIN Number by the DC1l.Certified agencles 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 DCJI via mail or by fax to(617)6 14. <br />