T O W N O F W E L L E S L E Y  M A S S A C H U S E T T S
BOARD OF SELECTMEN
Town Hall 525 Washington Street Wellesley, MA 02482-5992
781-431-1019 ext. 201 fax: 781-239-1043
AUTOMATIC AMUSEMENT DEVICE LICENSE
APPLICATION
Date Applied:
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Date Approved: |
Date Issued: |
Office Use Only
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Fees Paid: $100 per game |
Tax Cert: |
Resumes: |
CORI |
Floor Plan: |
Interview: |
The undersigned hereby applies for an Automatic Amusement Device License in accordance with the provisions of the State Statute relating thereto:
(PLEASE TYPE OR PRINT CLEARLY)
Name of Applicant:________________________________________________________________________________
D.O.B.______________________________ SS#____________________________ Dr. Lic.#_____________________
Fed. I. D. #_________________________________ Telephone #___________________________________________
Business Address:______________________________________ Home Address:_______________________________
Name of Manager:_________________________________________________________________________________
D.O. B.____________________________SS#____________________________ Dr. Lic. #______________________
Home Address:___________________________________________________________________________________
Name and Location of Establishment:__________________________________________________________________
Type of Establishment:________________________________Time(s) of Peak Customer Activity:_________________
Size of Floor Space (sq. feet)___________(enclose copy of floor plan) Number of Employees:______________________
List name, type of game, manufacturer and serial numbers (serial numbers begin with the letter “M”) all licensed amusement devices are required to be on the approved list of the Division of Standards.
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Date Applicant signature
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Applicant (please print)
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