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771e Commonwealth of Massach usetts <br /> Alcoholic Beverages Control Commission <br /> -- --------- 239 Causeway Street <br /> FI Boston,MA 02114 <br /> a( inviv.mass.g ovlabcc <br /> PERSONAL INFORMATION FORM <br /> Each individual listed in Section 10 of this application must complete this form. <br /> 1. LICENSEE INFORMATION: <br /> -- -- ------ -- ---------- B. Business Name(dba) The Inn at Hastings Park <br /> A. Legal Name of Licensee AB INNS, LLC <br /> -_---- - - ..-. . - <br /> 2013-2027Mascachusetts Avenue D.ABCC License Number 0039-HT-0612 <br /> C.Address (If existing licensee) <br /> E. City/Town Lexington State MA Zip Code 02420 <br /> F. Phone Number of Premise 781 301-6660 G. EIN of License 454-49-1852 <br /> 2. PERSONAL INFORMATION: <br /> A. Individual Name Trisha Perez Kennealy B. Home Phone Number 781-860-7771 <br /> C.Address 4 Brent Road <br /> D. City/Town Lexington State MA Zip Code 02420 <br /> E.Social Security Number F. Date of Birth i<k <br /> G. Place of Employment The Inn at Hastings Park <br /> 3. BACKGROUND INFORMATION: <br /> Have you ever been convicted of a state, federal or military crime? Ye"s No 0 O <br /> If yes,as part of the application process,the individual must attach an affidavit as to any and all convictions. The affidavit must include the city and state where <br /> the charges occurred as well as the disposition of the convictions. <br /> 4. FINANCIAL INTEREST: <br /> Provide a detailed description of your direct or indirect, beneficial or financial interest in this license. <br /> I am the-so I-e- proprietor of AB INNS, LLC with 100%ownership. <br /> IMPORTANT ATTACHMENTS(8): For all cash contributions,attach last(3) months of bank statements for the source(s)of this cash. <br /> *If additional space is needed, please use the last page <br /> l hereby swear under the pains and penalties of perjury that the information 1 have provided in this application is true and <br /> accurate: <br /> Signature -- -- --- Date <br /> Title Owner and CEO (If Corporation/LLC Representative) <br />