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O <br /> JS MORI{tNV � V N 0 U <br /> TOWN OF LEXINGTON D <br /> = �1p SELECTMEN'S OFFICE <br /> MAR 1 2017 <br /> A pm �9, <br /> L�XINGT�' APPLICATION FOR <br /> CLASS I, II, OR III LICENSE SELECTMEN <br /> The Board of Selectmen issues licenses for Class 1; II and III dealers. See back of this application <br /> for information on Class I, II and III licenses. Please fill in this form completely and return to the <br /> Selectmen's Office along with a check for S25.00 made payable to the Town of Lexington, the <br /> NVorkers' Compensation Insurance Affidavit form, the declaration page of your workers <br /> compensation insurance policy, CORI form; and if Class II license proof of S25,000 bond. <br /> CORPORATE NAME: L -Qxly4on A J+o Scd c., LLC <br /> D/B/A: <br /> ON-SITE MANAGER NAME AND PHONE NUMBER: D 8 $ U-- 1 0-7 O <br /> J]Z 0 e_r4 J t I VVLe4 Yl.S <br /> BUSFNESS ADDDRESS: <br /> EMAIL ADDRESS: <br /> TYPE OF LICENSE: A-Q A-o <br /> ADDITIONAL INFORMATION: <br /> Authorized Signature Federal Identification No. or <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 /> 4. For Class II License only: proof of S25,000 Bond <br /> 5. CORI form and drivers license or other government photo identification <br />