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BUSINESS CERTIFICATE TOWN OF MASHPEE I V � IJI (�UTL "1 r " 1`tG�s ��►'/ t Date: -- VExpiration Date: 3� In con for nit with the provisions of Chapter one hundred and ten, Section five of the General Laws, as amended,the dersigned hereby declare(s)that a business under the title of / /�/ 1 Corporation Name: Business Name/DBA: lv L✓ vV is conducted at Business Location: Business Type: l l New [�] Renewal [ ]--Commercial [ ] Residential [ ] Email Address: i Business Mailing Address: 5_ 4 / S% 9 V L-22—641 V 41 Business Telephone: Home [ ] Cell [ ] Phone: by the following named persons: Owner Name ��+' �� Owner Residence • I certify under the penalties of perjury that I, to the best of my knowledge and belief. have filed all state tax returns and paid all state taxes as required under law. *Signature of authorized agent **Social Security Number(Voluntary) 'This license will not be issued unless this certification is signed by applicant or Federa I Identification Number In case of emergency NAME: TELEPHONE NUMBER: Alarm Company: "Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing 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 Z / Personally appeared before me the above-named L- I 2 P ki an made oath that the foregoing statement is true. o 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 each four , YS there er s 11 g us such business shall be conducted and shall lapse and ttp•v 'd unless so rene . • Signed // Notary Puhlic Com Ori R