|
+Cornmonzvealth of Massachusetts
<br /> ........... Al
<br /> coho l c Beverages Control Commission
<br /> a' 239 Causeway Street,First Floor
<br /> C'' onM 02114
<br /> UURI
<br /> �yyam�++�ry�/-ryy �jr ��+ p * FORM JEAN
<br /> M. RIZIOx ESQ
<br /> T'.F�",EA S`U R AND RECEIVER GENERAL CHAIRMAN
<br /> The Alcoholic :beverages Control Commission ("A 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 /> ASCC LICENSE INFORMATION
<br /> A .CC NrJMBE t: t+6?O I081 LICENSEE NAME:NEW SEABU1. ....RY RESOURCES MANAGEM-- -1-----___�N`T, i CITY TOWN: iASHPEE
<br /> (IF I XiSTING LICENSEE)
<br /> ............_ ..............
<br /> �,�
<br /> .....................-.1-1-1111-11......... ............... .................................
<br /> APPLICANT INFORMATION
<br /> ..
<br /> ���������, �ro
<br /> LAST FAME: H OVER .................. � F`IRST NAME: sU� ............. ............ IDDLE NAME:
<br /> ......................... .....
<br /> a.....a................... .�.
<br /> I'►11AI DEN NAME OR ALIAS(I F APPLICABLE. � PLACE CIF BI RTI�I. �
<br /> "tV4
<br /> DATE OF BIRTH: �l SSN: I ThIEFT INDEX PIN 4IF APPLICABLE1: f
<br /> �annn ...m».nnn �naaaaa�� wwwwww:nona�fi guwwwwnuwrwr..:+.�- -„> ar.,n'nwmanmmnmr.,nna .._.__,...,wa..�n•,wwuwwwrzuar,xr mmH,n wwww�wv+wm��m,,,m.,,,„,p
<br /> MOTHER'S MAIDEN DAMEtot )RIVER' LICENSE 4: STATE LIC.ISSUED M,�� �Chu�E�tt a
<br /> __ ...�.� ����,� ...�al ......... ..... �. ��. ............ .._........_................_ �,TMoI
<br /> WEIGHT: `[ '""""�
<br /> GENDER:l=FEMAL HEIGHT: � �' � '� EYE COLOR:
<br /> ..............
<br /> CURRENT ADDRESS:
<br /> CITY/TOWN: DU BURY I STATE: FmA ZIP: 102332
<br /> t
<br /> FORMER ADDRESS:
<br /> CITY/TOWN: STATE: WV1 ZIP:
<br /> �— ........ �00
<br /> .,,na�R�R�R�R�R�����aR�R�R�R�R�R�R�R�R�R�R m,� ��a�,�� ������� �,
<br /> PRINTAND►SIGN
<br /> PRINTED NAME: ISUE A. HOOVER APPLICANT/EMPLOYEE SIGNATURE:
<br /> NOTARY INFORMATION
<br /> ........ _ .................................._....—,,, ........
<br /> Can this 12TH OF OVI 2019 fi before me the undersi S gned notary public,personally appeared A. H ► / F
<br /> aaaa
<br /> (name of document signer),proved tome through satisfactory evidence of identification,which were PERSONAL KNOWLEDGE
<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 /> TAMA► A VINCWjoya
<br /> NOTARY Puau
<br /> COMITI rnwealth of Massac'huseft
<br /> OMmiExpires
<br /> DIVIC�N�tsE ONL'� f ssct�n
<br /> .... ,,,,a., ��,M,,,, ��,� Mla�rcl"1
<br /> �u�ammmm...,
<br /> REQUESTED BY:
<br /> The DCIt Identity Theft Index Plat Number is to be completed by those applicants that have Been Issued an Identity Theft
<br /> PIN Number by the DOL Certified agencies are required to provide all applicants the opportunfty to include this
<br /> rnforrnation to ensure the accuracy of the CORI request process. ALL CORI request forms that inducle this field are
<br /> r�q iced to be submitted to the DCh via mail or by faK try(617) 60-4614.
<br />
|