Form 81-910 - License Application Amusement printable pdf download

WHEN COMPLETED MAIL TO: DEPARTMENT OF LICENSES

INSPECTIONS

AND

DEPARTMENT OF LICENSES AND INSPECTIONS

CITY OF PHILADELPHIA •

LICENSE ISSUANCE UNIT

LICENSE APPLICATION

PUBLIC SERVICE CONCOURSE

1401 JOHN F. KENNEDY BOULEVARD

AMUSEMENT

PHILADELPHIA, PA 19102

Follow instructions listed on the Instruction Sheet.

USE A SINGLE CHECK, OR MONEY ORDER FOR ALL FEES PAYABLE TO “CITY OF PHILADELPHIA”.

For further information call (215) 686-2490.

1. NAME OF OWNER (SEE 14)

2. BUSINESS NAME (IF APPLICABLE)

3. TELEPHONE NUMBER(S)

4. LOCATION OF LICENSED ACTIVITY (INCLUDE ZIP CODE)

OWNER NAME, ADDRESS AND TELEPHONE

ZIP CODE

5. BILLING ADDRESS (INCLUDE CITY, STATE, ZIP CODE)

CITY

STATE

ZIP CODE

6. BUSINESS INCOME AND RECEIPTS TAX NUMBER

7. COMMERCIAL ACTIVITY LICENSE NUMBER

8. FEDERAL TAX OR SOCIAL SECURITY NUMBER

9. DATE ACTIVITY STARTED

MONTH

DAY

YEAR

10. PUBLIC LIABILITY INSURANCE COMPANY AND POLICY NUMBER

11. GIVE ACTIVITY DATES IF NOT ANNUAL LICENSE

12. DESCRIPTION (BUSINESS, HORSE, NUMBER OF STALLS IN STABLES, ETC.

13. LICENSE TYPE

FEE

REVENUE CODE

EXPIRATION DATE

LICENSE NUMBER

AMUSEMENT, ANNUAL

$ 25.00

3001

12/31/

AMUSEMENT, DEVICE

25.00

7333

$0.00

AMUSEMENT, PERMIT (TEMPORARY) _____ DAYS @ $5.00 PER DAY Y

3026

12/31/

AMUSEMENT, VEHICULAR

20.00

3001

12/31/

$0.00

CARNIVAL _____ WEEKS @ $200.00 PER WEEK)

3028

WEEKLY

CIRCUS

25.00

3029

COMMERCIAL ACTIVITY LICENSE

250.00

3702

NONE

FOOD ESTABLISHMENT (RETAIL, NON-PERM)

110.00

3112

4/30/

ATTACHMENTS:

HEALTH APPROVAL

LETTER OF PERMISSION

TOTAL FEE $ _________________

14. OWNER, CORPORATION AND PARTNERSHIP (LIST THREE PRINCIPALS OR PARTNER'S)

HOME ADDRESS (INCLUDE CITY, STATE AND ZIP CODE)

NAME OF PRINCIPAL OR PARTNER

TITLE

15. APPLICANT CERTIFICATION

I hereby certify that the statements contained herein are true and correct to the best of my knowledge and belief. I

understand that if i knowingly make any false statements herein i am subject to possible revocation of any licenses

issued as result of my false application, and such other penalties as may be prescribed by law.

Applicant's Signature____________________________________________________________________ Date________________________

Address___________________________________________________________________________________________________________

LICAPP18

Form 81-910 - License Application Amusement

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