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-'!- BUSINESS CERTIFICATE#08 S <br /> THE COMMONWEALTH OF MASSACHUSETTS <br /> • TOWN OF MASHPEE <br /> DATE eg <br /> Expiration Date: December 31, 2012 <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 ` - <br /> DBA n r is conducted at <br /> Business Location:_/ <br /> Business Mailing Address: 177 C/ �l <br /> Business Type: Ph i A�I )n C Business Telephone: C--7 <br /> by the following named persons::: <br /> P,?+ULLM I 'RESIDENCE <br /> W tY J <br /> Home Phone <br /> 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 /> es as required under law. <br /> *Signature of authorized agent *Signature of authorized agent <br /> **Social Security Number(Voluntary) <br /> or Federal Identification Number <br /> In case of emergency <br /> NAME: TELEPHONE NUMBER: <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 subject 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 Massachusetts <br /> BARNSTABLE ss DATE L�b <br /> 'A r <br /> Personally appeared before me the above-named [ f✓CIZf✓i /Land 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 y ar/_thereafter solongas such business shall be conducted and shall lapse and be void unless so renewed. <br /> ed <br /> [L <br /> SEAL laq ic ' <br /> COMMONWEALTH OF MASSACHUSETTS <br />