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BUSINESS CER'T'IFICATE 4 09 - d v2 <br /> THE COMMONWEALTH OF MASSACHUSETTS A- <br /> TOWN OF MASHPE^E 2 <br /> • DATE <br /> Expiration Date: December 31, 2013 <br /> In conformity with the provisions of Chapter one hundred and ten, Section five of the General Laws, as amended, the <br /> undersigned hereby declare(s)that a business under the title of / <br /> Eh"G <br /> e'9 Z- DBA 141e,77- &N9 r is conducted at <br /> a <br /> Business Location: 4 F®rest Or ,/VU;ARee- 100 Oa(6-h19 <br /> Business Mailing Address: '2 Fare$-r Dr Zj:&9Amee Al 0�6�� <br /> Business Type: jl0A'V1'09rAr4Y Business Telephone: S-08 <br /> by the following named persons: <br /> FULL NAME RESIDENCE <br /> �hic G <br /> Am-e. 7— Y'2 ForeSy l)r /M-aA,2ee- , /'7A d-74,Y9 <br /> i <br /> Home Phone: SO$ <br /> Icertify under the penalties of perjury that I, to the best of my laiowledge and belief, have filed all state tax returns and paid all state <br /> taxes as required under law. <br /> nature of auth agent *Signature of authorized agent <br /> 6959 – 66 — 2-56rf <br /> **Social Security Number(Voluntary) <br /> or Federal Identification Number <br /> In case of emergency <br /> NAME: TELEPHONE NUMBER: <br /> Alarm Company: <br /> *This license will not be issued unless this certification is signed by applicant <br /> "Your social seewity number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax <br /> payment obligations. Licensees who fail to correct their non-filing or delinquency will be subject to license suspensioir or revocation. This request <br /> is made under the authority of Massachusetts General Law,Chapter 62C,Section 49A. - <br /> The Commonwealth of Massachusetts BAI2NSTABLE ss DATE-fVsj.nl, 1 3 <br /> Personally appeared before me the above-named Fir : C- C Mort Z _and made oath that the foregoing statement is <br /> true. <br /> A certificate issued in accordance with this section shall be in force and effect for four years from the date of issue and shall be renewed <br /> each four years thereafter so long as such business shall be conducted and shall lapse and be void unless so renewed. <br /> Signed <br /> • Margaret C. SantOS tary Public ' <br /> SEAL �iaf NOTARY,PUBLIC <br /> Commonwealth of Massachusetts <br /> My Commission Expires Sept.24,2010 Commission Expires: <br />