Petitioner: Application information
Applicant Information
| Manager / Owner Name |
Test User
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| Premises Address |
104 Spencer Ave Chelsea, MA 02150
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| Applicant Phone |
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| Applicant Email |
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| Days of operation |
Tuesday, Thursday, Saturday
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| Hours of operation |
9 AM - 5 PM
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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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| Occupancy Permit |
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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? |
Yes - renewal with changes (describe below)
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| Briefly describe any changes (renewals only) |
Reduced operating hours
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| Current License Number |
28282
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Entertainment Device Categories
| Number of Jukeboxes |
0
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| Number of Karaoke machines |
3
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| Enter 1 if dancing by entertainers/performers is offered |
1
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| Enter 1 if dancing by patrons will occur |
1
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| Enter 1 if light shows are offered |
1
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| Enter 1 if floor shows are offered |
1
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| Number of radios |
0
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| Number of TV screens |
0
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| Enter 1 if live shows are offered |
1
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| Enter 1 if use of amplification |
1
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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 |
0
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| Are tables owned by the petitioner? |
No (fill in following fields)
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Video Amusement Devices - provide the following information for each device (upload a separate sheet if necessary)
| Total Number of video amusement devices |
0
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| Owner status |
N/A - no amusement devices
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Petitioner: Attest and sign
Attest
| I have read and agreed |
Yes - accept terms and conditions
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| Contact telephone |
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| Federal ID Number |
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City: Internal tracking
For internal use / tracking
| Public Hearing Scheduled |
2017-10-24
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