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Commonwealth of Massachusetts <br /> Alcoholic Beverages Control Commission <br /> 239 Causeway Street,,First.Floor <br /> Boston,MA 02114 <br /> J� R�IH J�. IJ L.J JVBEJR��/ .I '�S T F M .ram , <br /> "' mmm� wawa ORIZI <br /> TREASURER A,t�►D.RE'CEI`VE'R'+ E21+'.�.�"RAL CIMI.�".�1 A 5� <br /> The Alcoholic Beverages Control Commission "ABCC") 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 cheep will be conducted on me,pursuant <br /> to the above.The information below is correct to the best of any knowledge. <br /> ABCC LICENSE INFORMAT`►Chic <br /> ABCC NUMBER: ���r ram' � LICENSEENAME: ��iITY"t`O N. <br /> (IF EXISTING UCENSEQ A <br /> A PPL►CA N T I►VFW?RMA T70 N <br /> LAST NAME: Mullen FIRST NAME: Scott MIDDLE NAME: Andrew <br /> MAIDEN NAME OR ALIAS(IF APPLICABLE): PLACE OF BIRTH: Boston,MA <br /> ........................... <br /> ............................................ .......... <br /> ................. <br /> DATE OF BIRTH: SSN: ID THEFT INDEX PIN(IF APPLICABLE): <br /> _` <br /> MOTHER'S MAIDEN DAME: DRIVER'S LICENSE#: STATE LIC.ISSUED.- Massachusetts <br /> GENDER: MALE HEIGHT: E 7 ,2 WEIGHT: 251 EYE COLOR: Brawn <br /> .....................7 <br /> CURRENT ADDRESS: <br /> CITYITE�V'I�'N: [centerville STATE: MA ZIP: F026327 <br /> FORMER ADDRESS: <br /> CITY/TOWN: Braintree STATE: MA ZIP: 02184 <br /> .. .......... <br /> PR►NT ANDS►G►11 <br /> ........ ........ mm..... <br /> PRINTED NAME: � �"� APPLICANT/EMPLOYEE SIGNATURE: <br /> NOTARY INFORMATION <br /> a <br /> Can this zo ► ' before me,the undersigned notary public,personally appeared ,t caq.................. <br /> name of document signer), <br /> � g ),proved to me through satisfactory evidence of identification which were (114 <br /> 'tat be the person whose name is signed on the preceding ear attached document,and acknowledged to me that(he)(she)signed it voluntarily for <br /> its stated purpose. <br /> NOTARY <br /> TAMA A VINCENT JOY E <br /> oTAI Y PUBLIC <br /> Commonweal,th of Massachusel <br /> DIVISION USE ONLY . . ----- My Commission Expires <br /> March 5. 2021 <br /> REQUESTED BY: <br /> Thee DCJI Identify Theft Index PIN Number is to be completed by those applicants that have been Issued an Identity Theft <br /> PIN Number by the D01.Certified agencles 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 are <br /> required to be submitted to the DC31 via mall or by fax to(617)6+60- 14. <br />