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2. Name of Applicant*
3. Name of Business*
5. Address of Business*
7. Business Mailing Address*
9. Email*
10. Phone Number*
12. Dancing

    1. By Patrons
    2. By Entertainers
    3. No Dancing
13. Music

    1. Recorded
    2. Juke Box
    3. Live Music
    4. Amplification System
    5. No Music
15. Shows

    1. Theatre
    2. Movies
    3. Floor Show
    4. Light Show
    5. No Show
16. Nudity

    1. Yes
    2. No

    Nudity, as described in M.G.L. c. 140, and 183A

18. Admission

    1. Yes
    2. No
19. Other

    1. Video Games
    2. Pool/Billiard Tables
    3. Other Auto Amusement
21. Please fully describe the proposed "Other"
23. lease fully describe the premises for the entertainment (inside, outside, patio, tent, etc.)
25. Please fully describe the proposed entertainment (Type, dates, hours of operation, indoors/outdoors, number of maximum attendees, etc.)
27. Today's Date*
    Today's Date
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29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

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