Petitioner: Application information
Applicant Information
| Manager / Owner Name |
Test
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| Premises Address |
124 Addison St Chelsea, MA 02150
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| Mailing address (if different) |
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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-Saturday 9 AM - 10 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? |
No - renewal without changes
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| Current License Number |
92828
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Entertainment Device Categories
| Categories of amusement device on premises (check all that apply) |
Jukebox, Floor Shows, Radios, TV Screens, Live Shows
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| Number of Jukeboxes |
1
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| Number of Karaoke machines |
1
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| Number of Radios |
2
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| Number of TV screens |
10
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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)
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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