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Alcoholic zero e Cctrc I Commission <br /> Causeway "treed first Floor <br /> N� Boston,.�!L�9t 02114 <br /> pV rcy �d wd� <br /> � u <br /> �}r gyp..., �+'t�+ i may + fir'+ P_E ) EST FORM <br /> DEL.)'RIRAIZ .�L.Tt..faLsB.CJB lJ 1 j r M <br /> TR.EA SURER AND R.ECEIVER GENF. L CHAIRMAIV <br /> The Alcoholic Beverages Control Commission "..A.BCC" has been certified by the Criminal I-Estory Systems :hoard 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 on rne,pursuant <br /> to the above.The i�nforrnation below is correct to the best of my knowledge. <br /> AHCC LICE. .__ <br /> a-www� � .�oe«.m <br /> 1 ABCC NUMBER: � 7 o 2 LICENSEE NAME:NEW EABUF�'�'Y'''F ESOUR E,S 1'�At"�l CEMENT,I CITY/TOWN: �f�1A HPEE <br /> {)F EXISTING LICENSEE) _ ..._....... ..A . w ....... <br /> APILLICANr►oRIi ArloN <br /> ...... . �.�. nn. "­' - ---------. . ��.�. .... ...... �. .................... <br /> ................. <br /> wwww � �..�. ««���r �, wry . r..�� w ��� .w �������.n����.w <br /> ........... <br /> . ..... <br /> ...... <br /> LAST NAME: HOOVER FIRST NAME: SUE � MIDDLE NAME: <br /> .................................... <br /> ..................... <br /> ............. <br /> MAIDEN,NAME t R ALIAS(IF APPLICABLE): � r�+ ��° PLACE OF BIRTH: �� <br /> „„ ....................... <br /> IWO.. l <br /> DATE OF BIRTH: I : I1)THEFT INDEX PIN(IF APPLICABLE): <br /> «.. .: <br /> mmmmmm�.oWWw....�.�..aaawwurwl�rbr+x+.mnm�>w»rrnn"immMnn�, �,nmmmnnn�mmmmn�mmmmmmwwmmmm..mmmmmmmrnmmvvwrv,�u.....ww ^�xe urr�rrm wua�N.'imrmmmmmmm�mrmmr vwa uav�uNHIIFIN/AJfY�'f/FXJHHJIWMNMri�ffYN/Hfr�mmmmmmr�muu uu wwwno�wmmmnn� swvnwva � <br /> MOTHER'S MAIDEN NAME: DRIVER'S LICENSE#: STATE LIC.ISSUED: Massachusetts <br /> ........................... <br /> 7 F__­ <br /> GENDER: FEMA <br /> LE HEIGHT: <br /> WEIGHT: EYE COLOR: <br /> CURRENT ADDRESS: <br /> .... w,�nw �,:_.. <br /> CITY/TOWN: DUXBURYTSTATE: MA ZIP: 022 <br /> FORMER ADDRESS: <br /> CITY/TOWN: ,, S T A T E: ZIP: 18061 <br /> � �,�u �n000 <br /> .................................. <br /> ....... <br /> ......... <br /> ........................ <br /> .......... .................. ............. .............. <br /> PR►NT A t►D SIGN <br /> ............ . . <br /> PRINTED NAME: SUE A. HCC /EFwoo <br /> APPLICANT/EMPLOYEE SIGNATURE: <br /> d <br /> ►Ir�C►rAR Y I1NFORMA TION <br /> rrrrrrr .., .....,.. ......... .........._._. <br /> � l ............. <br /> On this 12TH OFNOV, 019 before me,the undersigned notary Public,personal appeared <br /> J <br /> (name of document signer),proved to me through satisfactory evidence of identification,which were PERSONAL KNOWLEDGE <br /> ­­­"................................................................ <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 /> rMm r <br /> NOTARY.................... ............... � <br /> TAI ARA VINCE T JOYCE <br /> NOTARY PUBLIC <br /> Commonwealth of Massachuseft <br /> My Commission Expires <br /> .......................DIVISION N USE ONLY Y March 5, 2021 <br /> �,w+ur x�avw�rnmyrv,�w,rvm�w�ullmm�wWuulw�iuuu�upmwu�!�w .._.. ,,, <br /> RI ECIUESTED BY. <br /> .......... iiw..o�M <br /> i <br /> it �I4.7�/"i�/L1�����..//7/P4�1��✓✓r�7rf!'�F�C <br /> fhp 001 identify Theft Index PIN Number Is to be completed by those applicants that have been issued an Identity Theft <br /> PIN Number by the C301.Certified agencies are required to provide ail applicants the opportunity to include this <br /> inforrnaVon to ensure:the accuracy of the CORI request process. ALL CORI request forms that include this field are <br /> v requiredto be�su rr+ttect to the i C:I.r...W..a mail or by fax to(17 6 C 461,4. <br /> ............ a„ <br />