TAXICAB OPERATION/STAND LICENSE - Chelsea MA
TAXICAB OPERATION/STAND LICENSE
APPLICATION/RENEWAL FORM
(Use Pen Only - Print Clearly)
_____ Public hearing to Conduct New Taxicab Operation
(complete questions #1 through #6 only and CORI request form)
_____ Public hearing to Transfer Taxicab Operation License
_____ Public hearing for Additional Taxicab License(s)
(complete questions #1 through #6 only and CORI request form)
_____ Change of Officer(s) _____ License Renewal
_____ Change of Vehicle _____ Change of Registration
1) Corporation Name ____________________________________________________
2) Address _____________________________________________________________
3) Business Name _______________________________________________________
4) Business Telephone __________________________________________________
5) List names and titles of all officers of corporation, including the manager and all members of the board of directors. Give full name, home address, date of birth, and social security number for each:
Name and Title Address D/Birth Soc. Sec. #
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
6) Have you ever been convicted for violating any state or federal law?
Yes _____ No _____ If yes, explain: _____________________________
_____________________________________________________________________
7) Taxicab License #__________________
8) Mass. Registration # ______________
9) Vehicle Identification # ____________________________
10) Make ________________________________________________
11) Year __________________
12) Vehicle will be garaged at _________________________________________
_________________________________________
13) Insurance Company __________________________________________________
14) Insurance Company Telephone ________________________________________
I understand that any false statement on this application will result in immediate revocation of the license that was issued or reason not to issue the same.
__________________________________ ______________________________
Applicant's Signature Date
Return application to Licensing Department, City Hall, 500 Broadway, Room 307, Chelsea, MA 02150, with the following:
1) CORI Request Form;
2) Certificate of Good Standing from the Massachusetts Department of
Revenue;
2) Application fee (non-refundable) in the amount of $50 (check or money
order only), payable to the City of Chelsea (not applicable for
renewals).
Upon receipt of the above, you will be notified of the public hearing date. Upon approval of your application, you will be required to produce the following prior to issuance of a Taxicab Operation License:
l) Completed Insurance Verification Form;
2) $100 License Fee for each Taxicab Operation License
INSURANCE VERIFICATION FORM
License # _____________________________________________________
Registration # ____________ Vehicle ID #_______________________
Owner's Name __________________________________________________
Name of Corporation ___________________________________________
Insurance Carrier _____________________________________________
Insurance Agent _______________________________________________
Insurance Agent Telephone # ___________________________________
Rating Territory ______________________________________________
1
INSURANCE COMPANY
STAMP AND SIGNATURE:
The undersigned certifies that the above insured vehicle is garaged and rated in the City or Chelsea and further certifies that the insurance is in effect as of:
___________________________ _______________________________
Date Agent Signature
CORI REQUEST FORM
City of Chelsea Licensing Commission has been certified by the Criminal History Systems Board for access to conviction and pending criminal case data. As an applicant for the position of Hackney Driver. I understand that a criminal record check will be conducted for conviction and pending criminal case information only and that it will not necessarily disqualify me. The information below is correct to the best of my knowledge.
____________________________________ __________________________
Applicant Signature Date
APPLICANT INFORMATION
(Please Print)
____________________ ____________________ _____________________
Last Name First Name Middle Name
______________________________ _________________________
Maiden Name or Alias (If Applicable) Place of Birth
______________ ______-_____-_______ ______________________
Date of Birth Social Security Number Mother's Maiden Name
(Requested but not required)
Current Address: ____________________________________________________
Former Addresses: ____________________________________________________
Sex ____ Height _____ Ft._____ In. Weight _______ Eye Color ____________
State Driver's License Number: ______________________________
The above information was verified by reviewing the following form of government issued photographic identification: ____________________________
Requested by: _____________________________________________
Signature of CORI Authorized Employee
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.