20.125 Petitions to Operate a Bowling AlleyCity of Northampton
Application for Annual License
NORTHAMPTON, MASS.,
To the Honorable City Council of the City of Northampton:
The undersigned respectfully petitions your honorable body for a License as follows:
Name of Business: NorthamUton Howl
Type of License: BQW1Jnff License-Sundgy
Location of Business: 52S Pleasant Steet
Print Name of Applicant: (,/) S M B ch ae I 9
0r'�e
Signature of Applicant:
Address of Applicant: ()
In City Council,
Referred to Committee on Licenses.
ATTEST:
City Clerk
In Committee on Licenses,
Voted to recommend that Petition be
granted, not granted
ATTEST:
Clerk
In City Council, (date) Voted that Petition be granted
-not granted
Attest: Clerk to City Council
City of Northampton
Application for Annual License
NORTHAMPTON, MASS.,
To the Honorable City Council of the City of Northampton:
The undersigned respectfully petitions your honorable body for a License as follows:
Name of Business: Northampton Bowl
Type of License: BowlinLy License -Weekdays
Location of Business: 525 Pleasant Steet
Print Name of Applicant: M
Signature of Applicant: (1/
Address of Applicant: (V) No. Street P
In City Council,
Referred to Committee on Licenses.
ATTEST:
City Clerk
In Committee on Licenses,
Voted to recommend that Petition be
granted, not granted
ATTEST:
Clerk
In City Council, (date) Voted that Petition be
not granted
Attest: Clerk to City Council
granted
City of Northampton
STATEMENT OF ALL TAXES FILED AND PAID
Name of Business:
Location of Business:
Mort lamt n Bowl
525 Pl a ant to t
The licenses to operate Bowling on Sunday and Bowling on Weekdays will not be issued
unless this certification clause is signed by the applicant listed on the license.
1, (V) I r Y I i chae_ �r 4�� (print name of owner or authorized agent of the
business) certify under the enaltiaAf perjury p p luny that [, Co my best knowledge and belief, have
field all state tax returns and paid all state taxes as required under law.
(N) k'
Signature of Owner or Ag
NJ i or (V)-
Social Security Number
Federal Identification Number
Your social security number will be furnished to the Massachusetts Department of Revenue
to determine whether you have met tax filing or tax payment obligations. Licenses who fail
to correct their non -filing or delinquency will be subject to license suspension or revocation.
This request is made under the authority of Massachusetts General Law, chapter 62C, section
49A.
City of Northampton
AFFADAVIT OF WAGE COMPLIANCE
Name of Business: Northampton Bowl
Location of Business: 525Pleas nt Steet
The Northampton City Council, in determining whether to issue, re -issue, modify, suspend or revoke a
license. under G.L. c. 140,shall require that a potential or current licensee certify that they are not
subject to a federal or state criminal or civil judgment, administrative citation, order or final
administrative determination resulting from a violation of G.L. c. 149, c. 151, or the Fair Labor Standards
Act The City Council may require a wage bond or insurance be posted by any potential licensee who
does not certify that they are not subject to a federal or state criminal or civil judgment, administrative
citation, order or final administrative determination resulting from a violation of G.L. c. 149, c. 151, or
the Fair Labor Standards Act. Licensees that are subject to a state or federal debarment for violation of
the above laws, either voluntarily or involuntarily, or that have been prohibited from contracting with
the Commonwealth or any of its agencies or subdivisions shall be prohibited from holding, or continuing
to hold, licenses issued under G.L. c.140, for the entire period of debarment or other stated time
period.
Applicants must check box 1 or box 2 as applicable and must sign this Form, certifying compliance
with the requirements set out in this Form. This Form must be included with the application.
AFFADAVIT: (V) (Choose 1 below)
This License applicant is not subject to a federal or state criminal or civil judgment,
-vdminktrative r itatiorr, dM-17M 8T atimiffistrative determination resulting from a violation of
G.L. c. 149, c. 151, or the Fair Labor Standards Act within the last three years.
❑ This License applicant is subject to a federal or state criminal or civil judgment, administrative
citation, order or final administrative determination resulting from a violation of G.L. c. 149, c.
151, or the Fair Labor Standards Act within the last three years. This applicant will provide a
wage bond or wage insurance for the period of the license.
Nl:Y-M, 1 r )
(Typed or printed name of appl"Int) {Signature)