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BUSINESS CERTIFICATE �W . TOWN OF MASHPEE Date: (� Expiration Date: 18" In conformity with the provisions of Chapter one hundred and ten, Section five of the General Laws, as amended,the undersigned hereby declare(s)that a business under the title of Corporation Name: a / Business Name/DBA: is conducted at Business Location: M Fl l^ e Business Type: I` L I Ne ] Renew ] --Commercial [ ] Residential [ ] Email Address: Business Mailing Address: 32 C�15h n S Business Telephone: 73 MA3337 Home [ ]Cell [ Phone: by the following named persons: Owner Name Owner Residence I certify under the penalties of perjury that I, to the best or my knowledge and belief, have riled all state tax returns and paid all state taxes as required under law. 410 *Signature � asv *Signature of authorized agent **Social Security Number (Voluntary) -This license will not be issued unless this certification is signed by applicant or Federal Identification Number In case of emergency l� OG NAME: ¢l —ZI✓ft ��CGf TELEPHONE NUMBER: Alarm Company: "Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax fling or tax payment obligations. Licensees who fail to correct their non-filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law,Chapter 62C,Section 49A. The Commonwealth of Massachusetts BARNSTABLE, ss DATE Personally appeared before me the above-named J J5`A 6 -71 M A'I/ in and made oath that the foregoing statement is true. A ceni ficaic issued in accordance with this section shall be in force and effect for four years from the date of issue and shall be renewed each four y• hereafter so long as such business shall be conducted and shall lapse and b s oid unless so renewed. • Signed Notary Public G�(r Commission Expires & [J@borah Dami NOTAR • PUBLIC CWnnX IIMeeil':of MassachuS81t8 Mip COeMBhsit•r.Expires July 29,2016