Laserfiche WebLink
. AMEN ME T-- h f Mana er <br /> Gran a of License Mana r <br /> FORMATION A►. MICE llV _ <br /> 1The individual that has been appointed to manage and control the licensed business and premises. <br /> Pro used Manager Name So MULLEN M <br /> Date of SS <br /> Residential Address <br /> Email SMULLEN@NEWSEABUR'Y. oM Phone <br /> n......... mmm w <br /> Please indicate how many hours per week _ <br /> , mmmm mmmm �. <br /> you i � 5o ntend to be on the licensed premises Last-Approved License Manager <br /> 'PEDRO T GONZALEZ <br /> F <br /> 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? C Yes ro 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 /> utilizingthe <br /> he format below. <br /> Gate Municipality Charge Disposition <br /> C. EMPLOYMENT INFORMATION <br /> Please provide your employment history.Attach additional pages, if necessary, utilizing the format below. <br /> .Stan Date T End Date Position Employer Supervisor Name <br /> 03/2017 PRESENT FOOD&BEVERAGE M R NEW SEABURY RESOURCES M MT,INC +CHRISTOPHER D. CARD <br /> ........... <br /> 01/ 016 10/2016 GENERAL MANAGER V'ISCARIELLO HOSPITALITY GROUP SAMM'Y VIS+CARIELLO <br /> 1999 2015 OWNER PRESCOTT BROKERAGE SERVICES MARYBETH PRESCOTi' <br /> 1963 1999 GENERAL MANAGER BOSTON RESTAURANTS ASSOCIATION WILLIAM BAREZTE <br /> D PRIcF DISCIPLINARYR <br /> Have you held a beneficial or financial interest in,or been the manager of,alicense to sell alcoholic beverages that was subject to <br /> disciplinary action? ,Yes No If yes,please fill out the table.Attach additional pages.,if necessar ,utilizing the format below. <br /> State City ty j Reason o n for suspension,s p i��►.n revocation...... .....W..W..... <br /> Date of Action Name of License , orcancellation <br /> .... <br /> 1 hereby swear under the mmm gins a �P Innnn�y t information <br /> f provided <br /> � pp � �W�: <br /> p and penalties o perjury that the rn ormatran 1 hove rovrded rrt this a lrcatron rs true and accurate; <br /> m <br /> Manager's Signature Date <br /> //— My <br /> t <br />