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i <br /> RECEIVED <br /> TOWN OF LEXINGTON <br /> SELECTMEN'S OFFICE MAR U 9 2017 <br /> SE l <br /> « N LECTAIE1V <br /> APPLICATION FOR <br /> COMMON VICTUALLER LICENSE <br /> i <br /> The Board of Selectmen issues Common Victualler licenses to establishments that cook,prepare <br /> and serve food at tables. Please fill in this form completely and return to the Selectmen's Office <br /> along with a check for$25.00 made payable to the Town of Lexington,the Workers' Compensation <br /> Insurance Affidavit form, and the declaration page of your workers compensation insurance policy. <br /> i <br /> CORPORATE NAME: A l�u ow u s UL L <br /> D/3/A: <br /> ON-SITE MANAGER NAME AND PHONE NUMBER: <br /> rMavo <br /> BUSINESS ADDDRESS: z^11 Pa eel fyy-j S -, Ley.1n c,�Un yyt 67-`4 2--D <br /> EMAIL ADDDRES S: G Vyq t.i� . cam <br /> am <br /> HOURS: 5:00 a.m. - 10:00 p.m. Monday- Sunday <br /> ADDITIONAL INFORMATION: <br /> i <br /> Auth rized Signature Federal Ident ication MNoor <br /> t <br /> Social Security Number <br /> Submit to Selectmen's Office: <br /> 1. Application <br /> 2. Check for$25.00 (payable to Town of Lexington) <br /> 3. Workers' Compensation Insurance Affidavit(including copy of <br /> Declaration page of policy) ' <br />