Petitioner: Application information
Applicant Information
| Manager / Owner Name |
Test User
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| Premises Address |
500 Broadway Chelsea MA
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| Applicant Phone |
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| Applicant Email |
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| Days of operation |
Monday, Tuesday, Wednesday, Thursday, Friday, Saturday
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| Hours of operation |
M-F from 12 PM - 12 AM
Saturday from 10AM - 12 AM
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| Workers Compensation Certification (upload file) |
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| Wage Certification (upload file) |
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| Floor plan (hand drawn) to scale |
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| Certificate of good standing from MA Department of Revenue |
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Entertainment Device
| Entertainment Devices (check all that apply) |
Jukebox, Light Show, Floor Show, TV, Live Band
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| Days of operation (check all that apply) |
Friday, Sunday
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| Hours of operation |
9 AM - 1 AM
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Billiard Table Information (enter 0 if no billiard tables are included)
| Number of Billiard Tables |
0
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Pool Table Information (enter 0 if no pool tables are included)
| Number of Pool Tables |
1
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| Are tables owned by the petitioner? |
Yes
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| If not owned by the petitioner, please include owner information in the following fields: Owner Name |
NA
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| Table Owner Phone |
617-555-1929
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Video Amusement Devices - provide the following information for each device (upload a separate sheet if necessary)
| Number of video amusement devices |
0
|
| Name of amusement device |
NA
|
| Owner status |
Purchased
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| Serial Number of Device |
1
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| Manufacturer Name |
NA
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| Manufacturer Address |
500 Broadway Chelsea MA
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| Manufacturer Telephone |
+16175551010
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| Owner of Device |
Test test
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| Device Owner Address |
500 Broadway Chelsea MA
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| Other (detailed description) |
test
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| Upload photo of device |
CityGrows_sample2.pdf
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| Additional Devices (upload information) |
CityGrows_sample2.pdf
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Petitioner: Attest and sign
Attest
| I have read and agreed |
Yes - accept terms and conditions
|
| Contact telephone |
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| Federal ID Number |
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City: Internal tracking
For internal use / tracking
| License Commission Review |
Petition approved
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| Public Hearing Scheduled |
2017-09-07
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