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Commonwealth o,f Ma sachu of is <br /> fi <br /> Alcoholic Beverages Control Commission <br /> 239 Causewa ►Street,First.Floor <br /> Boston,MA 02114 <br /> �►RAr B. +JLBLBE"R RIRE <br /> TREASURER ANZI RECEIVER GENERAL CHAIRMAN <br /> The Alcoholic Beverages Control. Commission ""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 can me,pursuant <br /> to the above.The information below is correct to the best of my knowledge. <br /> ABCC LICENSE►NFORMA TION <br /> ABCC NUMBER. + + �+ LICENSEE NAME. Se�[,�t�,� " r CITY/Tow moshpeep <br /> (IF EKISTING LICENSEES ,u »»»»> <br /> APPLICANT INFORMATION <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: L .. SSN: Ifs THEFT INDEX PIN(IF APPLICABLE): <br /> «< ........ <br /> 7... <br /> .... �"""""".."�""m'^ �/::JIJFY YN�mmmmmmmmvmmmmnmmmmnnnnnwwxww�HNfH1NWNh'fXffmxmommmmmmm..mmmmmm .. <br /> MOTHER'S MAIDEN NAME: DRIVER'S LICENSE#: STATE LIC.ISSUED: Massachusetts <br /> GENDER: `MALE HEIGHT: 6 <br /> WEIGHT: 255 EYE COLOR: Brown <br /> ..<<.._J <br /> L <br /> CURRENT ADDRESS: <br /> CITY/TOWN: Centerville STATE. MA ZIP: 02632 <br /> r <br /> FORMER ADDRESS: <br /> CITY +OWN: Braintree <br /> /T STATE: 'MA ZIP: tJ2184 <br /> PR►NTAND SIGN <br /> PRINTED NAME: APPLICANT/EMPLOYEE SIGNATURE:co, Muk(tn <br /> NOTARY 1 NFORAdA TICIN <br /> On this f"lVelAtJev, Ztvlbefore me,the undersigned notary public,personally appeared <br /> �Zlmm mmm <br /> (name of document signer),proved to me through satisfactory evidence of identification,which were <br /> ,nn <br /> to be the person whose name is signed on the preceding or attached document,and acknowledged to me that(he)(she) fined it voluntarily for <br /> its stated purpose. <br /> g <br /> ni ... »rnmmmno®vwi wwrrt�m Y - <br /> .._....mwwwn . <br /> ICS TAI ARA VINCENT JOYCE <br /> * +IoTARY PUBLIC <br /> Commonwealth of Massa+chu <br /> �v r s �N� M Commi sslon Expir <br /> REQUESTED B: <br /> March , 2021 <br /> The D01 Identify Theft Index PIN Number Is to be completed by those applicants that have been issued an identity Theft'' <br /> PIN plumber by the DCII.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 ere <br /> required to be submitted to the DCIi via mail or by fax to(6171660-4614. <br />