Fillable Automatic Amusement Devise License Application Fillable PDF (Town of Douglas)

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Automatic Amusement Devise License Application Fillable PDF (Town of Douglas)

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TOWN OF DOUGLAS
AUTOMATIC AMUSEMENT DEVISE LICENSE APPLICATION
MGL c140(177a)
Date
Applicant Name: Business Addres:
Business Name: Mailing Address:
LIST NAME AND TYPE OF EACH COIN OPERATED DEVISE SEPARATELY:
Note: Pool Tables are licensed under a Pool Table License.
Devise Name:
Devise Name:
Devise Type:
Devise Type:
Devise Name: Devise Type:
Devise Name:
Devise Name:
Devise Name:
Devise Name:
Devise Name:
Devise Name:
Devise Name:
Devise Type:
Devise Type:
Devise Type:
Devise Type:
Devise Type:
Devise Type:
Devise Type:
I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax
returns and paid all state taxes required under law.
Signature
Title
To the Licensing Authorities:
The undersigned herby applies for a License in accordance with the provisions of the Statutes relating thereto.
Phone Number
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Automatic Amusement Devise License Application Fillable PDF (Town of Douglas)

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Completed 14 July 2020

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