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Paid $25.00 <br /> check# 2705 <br /> Jg MORIy�HG U U <br /> 0 O,p <br /> TOWN OF LEXINGTON FEB 2 4 2017 <br /> 4 nw A SELECTMEN'S OFFICE <br /> 3 <br /> APRIL 7QTH <br /> LFxING`r0 APPLICATION FOR I S.�LECTMEN <br /> COMMON VICTUALLER LICENSE <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 /> CORPORATE NAME: V-4+j IbG4 cttv .. j Kr, <br /> D/B/A: GouA ef�b <br /> ON-SITE MANAGER NAME AND PHONE NUMBER: <br /> BUSINESS ADDDRESS: Z3-S KA d. a.-C,G L _V-5 ,An2:e, L�2V—. <br /> EMAIL ADDDRESS: in C 0 <br /> HOURS: M 0(\J f�eA 1 '(� i 5�-4- R a 1AA - �^-► <br /> ADDITIONAL INFORMATION: <br /> Federal Identification No. or <br /> Authorized Signature <br /> Social Security Number <br /> IV�c� / <br /> Print Name Z 9 / x 7 <br /> Date <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 policy <br /> Declaration page or Certificate of Insurance) <br />