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. BUSENESS CERTIFICATE#67 / 1 <br /> THE COMMONWEALTH OF MASSACHUSETTS <br /> TOWN OF MASHPEE <br /> • DATE_� I - ( , 0 <br /> Expiration Date: December 31, 2011 <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 ^L <br /> �n DBA Q 1 Ill L is conducted at <br /> Business Location: Zj I r l��(� �j n ot ^ ;�Q �� o��LI9 <br /> Business viailino Address: \ ) (� Q I �� tl f l��S�l E P {�� 0 a (t y <br /> Business Type: hul O]Qnln Business Telephone: C5c Z� r) I Sy <br /> by the following named persons: <br /> FULL NAIME � ' t RESIDENCE <br /> C�11 �°� e On A n-aco 49 <br /> Home Phone: 50C6SaJ 1 (Q C O ( <br /> 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 <br /> taxes as required under law. <br /> ienatureTized agent *Signature of authorized agent <br /> **Social Security Number(Voluntary) <br /> or Federal Identification Number - <br /> In case of emergency G <br /> TELEPHONE NL MBER� <br /> Alarm Company: <br /> *This license will not be issued unless this certification is signed by applicant . <br /> **Your social security 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 subiect to license suspension or revocation. This request <br /> is made under the authority of Massachusetts General Law,Chapter 62C, Section 49A. <br /> The Commonwealth of rtfassachuselrs <br /> BARNSTABLE ss DATE / / / /,97 <br /> Personally appeared before me the above-named k rZw- rtj (3 F—; --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 m such business shall be conducted and shall lapse and be void unless s newed. <br /> Signed <br /> EAL• - Notary Public <br /> �, OSEPH 1.MAMJCCHEW j� <br /> CommowmiA21Wl Z <br /> MYC mssbnEs{m <br /> OckbM [9 <br />