Petitioner: Applicant Information
Rooming House & Manager Information
| Name of rooming house |
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| Rooming house address |
21 Fifth St/253-255 Chestnut St
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| # of floors |
3
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| # of rooms |
29
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| # of lodgers |
58
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| Rooming House Telephone |
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| Manager Name |
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| Manager Home Address |
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| Manager Telephone |
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| Manager Email |
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Renewals (please complete all fields if this is an application for a renewal)
| If this is a renewal, has any information changed from your original license application? |
No - renewal without changes
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Owner Information
| Owner Name |
Campbell Investment LLC
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| Home Address |
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| Home Telephone |
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| Owner Email |
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Certificates (required)
| Certificate of Worker’s Compensation OR Certificate of Compliance (must be notarized) |
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| Wage Theft Certification Form |
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| Certificate of occupancy or application for same |
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| Business Certificate or Articles of Organization |
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| Certificate of Good Standing from the Massachusetts Department of Revenue; |
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Petitioner: Acknowledgement
Applicant Certification
| I have read and agreed |
Yes (Yes - accept terms and conditions)
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| Enter telephone number |
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