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5 &
<br /> 6. AMENDMENT-Chlan", ,!p,,,,,,,,,.,of Officers, Stock or Owner4",.Interest
<br /> ...........
<br /> �;!mriigv of-owners, interest F-104ne of Stock(9,,q,New Stockholder/
<br /> [RChq119� _of Office rs/D i rectors [I , ' — ...............................
<br /> ......... ALLC Man sL LF Partners,Trustees
<br /> Transfer or Issuance of Stock
<br /> ..................................................................................._-
<br /> List all individuals or entities that will have a direct or indirect,beneficial or financial interest in this license(E.g.Stockholders,Officers,
<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-Restaurant/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 area Multi-Tiered Organization,please attach a flowchart 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 /> SSN DOB
<br /> ICHRISTOPHER D CARD
<br /> I..................
<br /> ................ ..................:1
<br /> Title and or Position Percentage of Ownership, Director/LLC Manager US Citizen MA Resident
<br /> PRESIDENT/DIRECTOR
<br /> Yes C No re Yes C No r Yes r* No
<br /> ,L070
<br /> Name of Principal Residential Address SSN DOB
<br /> ................. .................................................. .......... ......... ...............
<br /> COFFEY
<br /> ............ ............... ------------
<br /> Title and.or Position Percenta e of Ownershi Director)(LLC Manager US Citizen MA Resident
<br /> ........................................._`_"................................
<br /> ................."1 11 1
<br /> SECRETARY/VICE PRESIDENT 0
<br /> ............................. Yes CNo Yes C No Yes C No
<br /> .
<br /> Name of Principal Residential Address SSN DOB......................... .................................. ..........
<br /> ..........
<br /> .......................................................... ....................................... ..........
<br /> SUE HOOVER
<br /> --—-—--------------
<br /> Title and or Position Percentag Director/LLC Manager US Citizen MA Resident
<br /> of Ownershi
<br /> .............
<br /> 0
<br /> 11 S IDENT 10% ............... F, es C No Yes ("No
<br /> ........
<br /> Name of Principal Residential Address SSN DOB.............................
<br /> ............................... ...........— ........—---------------------------............................... ..........................
<br /> .........
<br /> . ...... ........... ——----
<br /> Title and or Position e 11
<br /> —.Percenta of Ownershi, Director/LLC Manager US Citizen MA Resident
<br /> ..............
<br /> CYes ( No
<br /> C—No..................
<br /> CYes CNo Yes
<br /> Name of Principal Residential Address SSN DOB
<br /> ........................................... .................................................... ....................................
<br /> E........ .............................................. ...... ............
<br /> Title and or Position Perc e of OwnershipDirector/LLC Manager
<br /> US Citizen MA Resident
<br /> ..........
<br /> .......... ........................ 0...............
<br /> ....................._................................................................................. Yes No C Yes No ( Yes ( No
<br /> wwti
<br /> ............ -------..........—1
<br /> Name of Principal Residential Address SSN
<br /> DOB
<br /> R
<br /> L.................................... ...............1 11
<br /> Title and or Position ................................... Percenj,age"of Ownersh�� Director/LLC Manager US Citizen MA Resident
<br /> ............... ................................... .................
<br /> ------- C Yes No ( Yes C No C Yes C No
<br /> ---—------ ... .
<br /> Additional pages attached? ........................ ..........
<br /> Yes re-No—
<br /> CRIMINAL HISTORY ...............
<br /> ..................
<br /> Has any individual listed in question 6,and applicable attachments,ever been convicted of a Yes re No
<br /> State,Federal or Military Crime?If yes,attach an affidavit providing the details of any and all convictions. ..............................
<br /> MANAGEMENT AGREEMENT
<br /> Are y...6 u—,'r,—eq 6--e"—s t—in,...............g................a"""p"'p,ro"',v—al,,to utilize a management company through a management agreement?
<br /> Please provide a copy of the management agreement. ( Yes �" No 8
<br /> ..............
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