Routing slip + Health Dept. Notification Form (002) CITY OF SALEM,MASSACHUSETTS
N`°r " LICENSING BOARD
`\ 93 WASHINGTON STREET 2nd FLOOR
a�t red. SALEM,MA 01970 ROBERT rut sr.PIERRE,CHAmwA
TEL.978-745-9595 EXT.5631 PAUL FLORES
(c<a�
FAX 978-744-1279 RICHARD C LEE
KIMBERLEY DRISCOLL
MAYOR VIELISSA PAGLIARO,
CLERK OF THE BOARD
ROUTING SLIP
The Salem Licensing Board requires each applicant to have the appropriate Departments sign this
Routing Slip and return it to the Licensing Board Office prior to the issuance of a license.
BUSINESS NAME I L L -
Corporate name: � vt c=W.�: S<l�
d/b/a: G L Vxc_Muyi (C
LOCATION: l �ks� S :�y�.c , S <�r , Tele. #
TYPE OF LICENSE:
APPLICANTS NAME:
Residence
Street: e- Hometelephone#
City: B c or,( HA C-) I <( c 1 State: Zip:
***TO ALL CITY DEPARTMENTS: Your signature on this form is notifying the Licensing
Board that all requirements of your department have been met, at which time the Licensing
Board will issue a license.***
try Salem Historic Commission DATE j�"J/Sign/Review Planning Dept. DATE
120 Washington Street 120 shington Street
i
20 (8
(� Salem Health Department DA>� Fire Prev ntion DATE '
120 Washington Street 29 Fort Avenue
6�7Y- 7-1/5 ' � 777
11- 7a �/,0 O /, �nAu� -lam va — I-z3-1�
Building Inspector DATE /Depf. of Public Services DATE
120 Washington Street (Water Dept.) 120 Washington Street
CITY OF SALEM,MASSACHUSETTS
�� LICENSING BOARD
93 WA51UNGTON STREET 2-4 FLOOR
I' 15'_ (� SALEM,MA 01970
\�`ti�� ROBERT M.ST.PB:RRE,CHAIRMAN
TEL. 978-745-9595 EXT, 5631 PAUL FLORES
KIMBERLEY DRISCOLL FAX 978-744-1279 RICHARD C.LEE
MAYOR MELLSSA PAGUARO,
CLERK OF THE BOARD
HEALTH DEPARTMENT NOTIFICATION FORM
IF YOUR APPLICATION INCLUDES THE SERVING OF FOOD YOU HAVE THIS FORM SIGNED BY
THE HEALTH DEPARTMENT PRIOR TO SUBMITTING YOUR APPLICATION TO THE LICENSING
BOARD. THIS FORM MUST BE SIGNED AND RETURNED WITH YOUR APPLICATION TO THE
LICENSING BOARD.
NAME OF BUSINESS(d/b/a): wt K tite- "n
CORPORATE NAME: !!G t py G S ! ( L(—C
ADDRESS: C * t4
CONTACT NUMEBR#:
TYPE OF LICENSE APPLYING FOR: 1�l e-t LJ c P
APPLICANTS INFORMATIONa^ A' ` ` rr C
Name: �G4 VQti NtS c
Home address: G lli (c A L
City: B E u e i L State: 1 `A-
Zip: 11 c
HomeTete.#: Cell#: - -t b`z
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HEALTH AGENT/INSPECTOR' CO NTS:
,.�7-73 R'b l IN
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DATE_ I23 ( �
Health nt
Updated 1/13
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