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' BUNE <br /> THECOY7ititO+YTVE.aLTHOFiYtASSACHUSETTS <br /> T0W_1V OF AfASHPEE <br /> DATE <br /> Expiration Date: Deceitzber 31, 2012 <br /> In conformity .with the provisions of Chapter one hundred and ten, Section five of the General Laws, as amended. dje <br /> undersigned hereby declare(s) that a business under the tide of <br /> ?) (kink iNw i_u DBA Mnft t4 If,)U is conducted at <br /> Business Location: (d TatI YhOLI-ky) OQ(0k4`1 <br /> Buiiness VlailingAddress:_J` <br /> Business Type:_n(�}f Business Telephone: 506 <br /> by the following named persons: <br /> 17 <br /> Fli N.Ar� RESIDENC <br /> Home Phone: 7 /V— '� <br /> Icertiry and r e penalneOf perjury that L to the best of my knotwledge and belief. have filed all state tax reruns and paid ail state <br /> taxis as re e and <br /> Am 1114 JA <br /> _ mre or audtorized anent =Sienarure ofauthorized aLent <br /> N 3� -01/64 7- 3��D <br /> '*Social Security Number(Voluntary) <br /> or Fzdzral Identification Number <br /> _�p In case of emergency <br /> NAMla'� <br /> E:-;Yaka NA&hm '�+P TELEPHONE YU.4BER:03'5-5-7 <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 iMassachuseas Department of Revenue m determine whether you have met tax filing or rte: <br /> payment obli_arions. Licensees who fail to correct their non-filing or delinquency will be subject to license suspension or revocation- This request <br /> is made under the authority of Massachusetts General Law,Chapter 62C.Section'9A. <br /> B.ARVSTASLE ss <br /> The Conmtonweaf h of Afassac/arserts � <br /> - DATE <br /> Personally appeared before me the above-named ��l"'�� N �C.naV1"K/> 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 vears from the date of issue and shall be renewed <br /> each four year ther r soIonsuch b 'iess shall be conducted and shall lapse and be void unless so ewed. <br /> �idned // � <br /> • i4 <br /> SEAL votary Public <br /> Deborah F. Dami <br /> o,g NOTARY PUBLIC 'Commission Expires: <br /> t`IL� Commonwealth of Massachusetts <br /> My Commission Expires July 24,2009 <br />