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TOWN OF MASHPEE <br /> • Statement of Discontinuance,Change of Residence,Change of Location of Business, <br /> Withdrawal,or Deceased from Business or Partnership,Change of Business Name or Owner Name <br /> .......... ................... <br /> DATE <br /> In conformity with the provisions of Chapter one hundred and ten, section five, of the General <br /> Laws, as amended,the undersigned hereby declare(s)that I/We has (have)this day discontinued(retired <br /> from) (withdrawn from) the business of................................................................ <br /> conductedat .......................................................:...................................... <br /> STREET <br /> In the Town of Mashpee. <br /> ....................................................... <br /> SIGNATURE <br /> I hereby state that the location of the business/my residence as it appears on the Business <br /> Certificate filed on ................................has been changed to .................................. <br /> .............................................................................................................. <br /> ........................................................ <br /> SIGNATURE <br /> I hereby state that the name of the business or the owner as it appears on the Business Certificate <br /> has been changed, <br /> from ............... (-..i . <br /> tD... 7�1. ....�................. , ..../���.... ..&............ ...©.. .... 'x.�r S <br /> SIGN DATE <br /> �� ✓n.s (?�blg ..55. CK // C t. actor <br /> Personally appeared before me the above named...' sQ.b.!?...M .....and made <br /> oath that the foregoing statements are true. <br /> ........................ <br /> MTI L.SCOTT <br /> Notan Public �d �s✓ � <- <br /> CommomNotar of Massachusetts. ..... ...... ............ ........./..... ....................... <br /> My Commission Expires <br /> March 31.2006 ....U.`. .L.d vC.�.... a.. c5 4 <br /> ................... <br /> Commission Expires <br /> Origform/Disconunuance <br />