City of Woburn, Massachusetts LICENSE COMMISSION APPLICATION FOR COMMON VICTUALLER’S LICENSE Fee: $100.00 Date:___________________ NAME OF RESTAURANT:_________________________________________________________ ADDRESS:_______________________________________________________________________ TELEPHONE:_____________________________________________________________________ NAME OF OWNER:________________________________________________________________ ADDRESS:________________________________________________________________________ TELEPHONE:______________________________________________________________________ DESCRIPTION OF PREMISES:________________________________________________________ ___________________________________________________________________________________ GIVE NUMBER THAT CAN BE ACCOMMODATED AT TABLES__________________________ AT COUNTER_______________________________________________________________ HOURS OF OPERATION:_____________________________________________________________ IF NEW LICENSE, IS FAST FOOD SPECIAL PERMIT NECESSARY?________________________ DATE RECEIVED______________________________________________________________ SIGNATURE OF MANAGER:__________________________________________________________ PREMISES INSPECTED BY: BUILDING DEPT. __________________________________________ 932-4440 HEALTH DEPT.____________________________________________ 932-4407 FIRE DEPT.________________________________________________ 932-4580 POLICE DEPT.______________________________________________ 932-4532 ALL MUNICIPAL TAXES AND FEES MUST BE PAID PRIOR TO LICENSE APPROVAL. (see attached form) TREASURER________________________________________________ 932-4483 LICENSE MUST BE RENEWED ANNUALLY ON OR BEFORE MAY 1ST *Massachusetts Workers’ Compensation Insurance Affidavit and City of Woburn Treasurer’s Certificate must be submitted with this form. **This license, if granted, cannot be transferred or sold. Any changes in floor plan, hours, or addition to entertainment must be approved by the License Commission. American LegalNet, Inc. www.FormsWorkFlow.com