21.269 Northampton Bowl Weekday Bowling LicenseCity 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: Bowling i n -W k
Location of Business: 52S Pleasant Steet
Print Name of Applicant: (v) (�e
Signature of Applicant: C1Alt
Address of Applicant: Cd) NoStreet
In City Council,
Referred to Committee on Licenses.
ATTEST:
City Clerk
In City Council,
date)
In Committee on Licenses,
Voted to recommend that Petition be
granted, not granted
ATTEST:
Clerk
Voted that Petition be granted
not granted
Attest: Clerk to City Council
City of Northampton
AFFADAVIT OF WAGE COMPLIANCE
Name of Business: Northampton Bowl
Location of Business: 5-2-5-Pleasan
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,
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 License applicant is subject to a federal or state criminal or civil judgment, administrative
�j 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.
(Typed or printed name of applican
City of Northampton
STATEMENT OF ALL TAXES FILED AND PAID
Name of Business:
Location of Business:
Northampton wi
2 5 Pl asanI Steet
The license (as a/for a) Bowling License -Sunday will not be issued unless this certification
clause is signed by the applicant listed on the license.
1, (�) print name of owner or authorized agent of the
business) certify under the penalties qof that I, to my best knowledge and belief, have
Field all state tax returns and paid all state taxes as required under law.
N)
y
Signature of Owner or Ag
9�/
V`�
(d) - 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
Treasurer/Collector's Office
Permit Denial Form
Revised 11-30-201 S
REQUESTED BY: Pamela L. Powers, City Clerk
Name of Person, Corporation or Business: Northampton Bowl
Location of Property, Service or Address: 525 Pleasant Steet, Northampton, MA 01050
All permits denied for outstanding amounts must receive confirmation of good standing
from the Treasurer/Collector's Office PRIOR to issuance of the permit.
For Tax Collector's/Treasurer Is Office Use Only
Please list below any tax, assessed to your officc that is unpaid for twelve (12) months or
more after its due date, unless there is a pending abatement or appeal before the Appellate
Tax Board, for the person, corporation, or business entity noted above.
No confirmable outstanding obligation 12+ months beyond due date.
Signed:
Adopted 5-21 1992 [Ch 14 S.I4-21 of the 1977 Code]
Denial/Revocation of License
Dated: 4/28/2021
City of Northampton