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6. ►AMENDMENT-Ch <br /> rvr" <br /> apge of 0ff1wC%r-;;1rs S-it-ock oinnr Ownersh Interest <br /> Oops of Owners.hlp Interest F� Chapgg of Stock[g,ChAng of officers/Directors F New Stockholder/ <br /> . . . cif...................... ALLC Ma .......... ..................... YYY .... .................... <br /> ... .......nAqer;�. w-ftrtnes Trustees` Transfer or Issuance of Stoc I <br /> —-—------......... ——----------.......... . .....* <br /> List all individuals or entities that will have a director indirect,beneficial or financial interest in this license(E.g.Stockholders,Officers, <br /> I <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.Restaur'ant/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 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 /> ......................—----- SSA DOB <br /> ................................................. <br /> C HRISTOPHER D CARD '149 <br /> .......... <br /> Director/LLC Manager US Citizen MA Resident <br /> Title and or Position Percenta�ge of Qwnershil <br /> ............... <br /> ....................... <br /> Yes ( No (*'Yes ( No ( Yes (*'No <br /> ---�IDENT/DIRECTOR .............. I <br /> p <br /> IL'PR(............................................. 00/ <br /> .............................................................................--­-"-'-"'; . I.................... <br /> Name of Principal Residential Address SSN DOB <br /> LORRAIE J. F EY <br /> Title d or position �rv�m� <br /> Percentage of Ownershi Director/LLC Manager US Citizen MA Resident <br /> ........................................ <br /> SECRETARY/VICE PRESIDENT 0/0 *' Yes ( No ......... .................. ...... <br /> ...........-............ ............. Yes No Yes CNo <br /> Name of Principal Residential Address SSN DOB <br /> ........................ ............... ................................................................... .............. .......................... ........................................................................... <br /> F............. <br /> S#JE HOOVER <br /> ............................................... <br /> Title and or Position PercentNe of Ownersh�) Director/LLC Manager US Citizen <br /> ......... MA Resident <br /> .TREASURER/VICE PRESIDENT <br /> Lr—* �Yes C No C No <br /> Name of Princi Res idential Address <br /> SSA DOB <br /> ................................................. ............................................................ ............................................ ...... ................ ...... <br /> ......... ............................... .......... <br /> ........... <br /> Title and Position <br /> Percenta,,ge of Owner Director/LLC Manager US Citizen MA Resident <br /> .......... <br /> ........... ................................... <br /> -------............................ 1--l.l.,�,�,����������������-�-�,�,�........................ ......... C'Yes C No ( Yes ( No Yes C No <br /> ............. ........ <br /> Name of Principal Residential Address SS DOB <br /> ............ ................... ................................................ .................-;.............. ............................................... <br /> ............ --—-—-,—a------------------------------------ ............. E............... <br /> Title and or Position P e rc e n ta'_qe of Owners"h Director/LLC Manager US Citizen <br /> ................................................... ...................... ............................. ................. <br /> Yes ( No.............................. ( Yes ( No MA Resident <br /> F..... ...... ( Yes (7 N <br /> ""'......................................................................................................................................................................................... --------- LC <br /> Name of Principal Residential Address SSN DOB. .......................................... .............................................................. ............................... <br /> Title and or Position Per�en age of Ow' nershi Director/LLC Manager US Citizen MA Resident <br /> C Yes C No <br /> ................... <br /> "`Yes Igo <br /> ...................................... <br /> C Yes C No <br /> ............ <br /> .................................... ............................................. <br /> Additional pages attached.? r Yes 6 No <br /> HIS L ORY <br /> CRIMINAL.................... .... .......... <br /> Has any individual listed in question 6,and applicable attachments,ever been convicted of a 'No <br /> L C Yes (o <br /> State,Federal or Military Crime?If yes,attach an affidavit providing the details of any and all convictions. .............. <br /> MANAGEME AGREEMENT <br /> Ai"6"' NT y'o'-"u' requesting g—a p, p-i o-v-�a`-I to utilize a management company through a management agreement? ( Yes (*'No <br /> Please provide a copy of the management agreement. 8 <br /> . ........... <br />