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is <br />Name and <br />THE COMMONWEALTH OF MASSACHUSETTS <br />FEE r% ✓�� <br />m ft5ttP E e <br />(city or town) <br />APPLICATION FOR PERMIT TO CONDUCT RAFFLES AND BAZAARS <br />(C. 810, ACTS OF 1969) <br />of Nonprofit Organization: <br />M <br />Evidence of Qualification for Permit: <br />❑ (a) Veterans' organization chartered by the Congress of the United States or included in clause (12) <br />of section five of chapter forty of the General Laws; or, <br />❑ (b) Church or religious organization; or, <br />❑ (c) Fraternal or fraternal benefit society; or, <br />❑ (d) Educational or charitable organization; or, <br />❑ (e) Civic or service club or organization; or, <br />❑ (f) Club or organization organized and operated exclusively for pleasure, recreation and other <br />nonprofit purposes, no part of the net earnings of which inures to the benefit of any member or <br />shareholder. <br />Officers or members of organization responsible for operation of raffle or bazaar: <br />Name <br />Residence Address <br />(1) h'IlcllaP l �cc ••.ntiad E�ce'.cc)i)u��tfPCi'ri G!n-Sos����alz.e '�.cdZ�19 `(f�2�.rcJ`c6(/�19 <br />(2) AiC ("42 :D00a , -?9-E5 (W -NT zy Cn lyt-1 a,�scrltu� r g o a3 (1 <br />(3) �i a Frzc SP/ 72C1g5u2e�L Z`t ruo-S Cb JRTf�SiHt3ti nn W e a ? 6'� <br />Uses to which net proceeds will be applied: �/DUTH)LR CIONH� �R �C�•10W m:� <br />FORM 810 Rev. 12/81 H Homs& WARREN rM <br />(signature of authorizja officer or member of organization) <br />The Applicant (is) (is not) qualified to operate raffles and <br />bazaars under the provisions of C. 810, Acts of 1969: <br />fvA Z`� <br />Chi f of Police <br />OVER <br />Application certified to be in <br />confor ity with C. 10, is <br />of 1969 <br />City/Town CI rk <br />PERMIT (ISSUED) 00109 <br />�tcr� 3,2m9 <br />(date) <br />s <br />• <br />City/Town Cl rk <br />FORM 810 Rev. 12/81 H Homs& WARREN rM <br />(signature of authorizja officer or member of organization) <br />The Applicant (is) (is not) qualified to operate raffles and <br />bazaars under the provisions of C. 810, Acts of 1969: <br />fvA Z`� <br />Chi f of Police <br />OVER <br />