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# <br /> cant. <br /> Date of state of Date qualified to do business in <br /> d# incorporation: e. incorporation: f. the.Commonwealth of Massachusetts: <br /> xach a copy of approved certificate of ranition <br /> . If applicant is a club,, association, limited p r nership, or other, type of-organization: <br /> a. List for each principal officer: Note - Each association member who signs this application must answer this question) <br /> T1 TLE FULL. AME.- _ HOME ADDRESS TELEPHONE LJI BER <br /> b. Trade, firm or business name: <br /> Address: Telephone-no. <br /> f applicant has a d/b/a. applicant must include a copy of the certificate of doing business, required under Massachy set-s <br /> Genera l Laver Clap, l 10. Sect. 5, regard les s of which name wil l appear on the license} - <br /> ,_ State name, address and telephone number of a person who can be contacted concerning this application; <br /> &M . A( J �� <br /> 1-0 2 y L <br /> S. .Add'ress and tele h e of premises to he. licensed: rt, <br /> 1 SS I Mr)� -&2�2 <br /> . Give a full and co4ete description of the premises to be licensed, 'Including locaticri of all entrances af-nd exits: <br /> 2L <br /> r I r) <br /> to. a. mill there be any major remodeling, redecorating or building on the premises in preparation for qui ition of this dense? <br /> E]Yes �o If yes. complete b, c, d, and e. <br /> b. Gine a brief description of the planned charges: ��� <br /> ��6y)lin L7 aUrp A YU CLA/j*iji a <br /> C.' OL Lk kd �, Sorg pe +r'Rcrlil <br /> . Estimated costs: d. construction schedule; <br /> e, State all sources of financing; CA" <br /> j <br /> 11, a. Does the applicant own the premises. to he licensed? Yes [2N o If no, state; <br /> I. blames, addresses and telephone number of owners: <br /> ..� . <br /> Illy 0 <br /> . Indicate whetherpR licarrt will be a RLessee ElSublessee ClAssignee or 11 then <br /> Specify other: <br /> Y <br />