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BUSINESS CERTIFICATE q OS 3 <br /> -' THE C0111,1101WEALTH OF AVASSACHUSETTS <br /> TO WV OF NIASHPEE <br /> • DATE <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 /> undersisned hereby declare(s) that a business under the title of _ <br /> DBA is conducted at <br /> Business Location: <br /> Business Mailing Address: <br /> Business Type: Business Telephone: <br /> by the following named persons: <br /> FULL NAME RESIDENCE <br /> Home Phone: <br /> I certity under the penalties of perjury that h 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 /> �Jiunanue of authorized agent *Signamre of authorized'ag*ent <br /> "Social Security Number(Voluntary) - <br /> or Federal [densification Number <br /> In case of emergency <br /> NAME: - TELEPHONE NliMBER: - <br /> Alarrn Company: - <br /> ,This license will not be issued unless this cert <br /> i[ication 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 filinv or taz <br /> pucment obli_ations. 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 Vassachu.setts <br /> BARNSTABLE ss DATE <br /> Personally appeared before me the above-named 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 solongas such business shall be conducted and shall lapse and be void unless so renewed. <br /> Signed <br /> • SEAL Notary Public <br /> Commission Expires: <br />