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BUSINESS c]'sR'1'ITICATE N 09_&_ � <br /> THL COMn9ONYVEALTN OFn9ASSACBusETTs <br /> TO IVA/OF MASIIPEG . Q <br /> DATE / B� <br /> Expiration Date: December 31, 2013 <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 tire title of <br /> t/-- 1+0�iP�,G.� SBA /.�d/'�f,$fpm <,(%U!/�(j�.E�iS l., conducted at <br /> _Buussiness Location:_zr.O--�/9/fl'!,/7�df��/ / ,�,JJ���if <br /> Business Mailing Address: �� !v/0�( �j y� /Q�o 47— 'G� ' � <br /> Business Type:lw �r �n C/�'la�� Business Telephone: ,J—� 7s/�`ep— 77— 9;�' or Ple <br /> by the following named persons: <br /> FULL NAME RESIDENCEp <br /> 5 —IAF';P—' et/4`•t' A14 J iOlf/r7i��,�dsvb f7Uir/ .�/9 <br /> Home Phone: <br /> I certify underthe 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 w. <br /> .ature of auth rzed agent email address <br /> "*Social Security Number <br /> or Federal Identification Number <br /> Lt case of emergency <br /> NAME: TELEPHONE NUMBER: <br /> Alarm Company: - <br /> **Your social security number will be furnished to the Massachusetts Deparnnent of Revenue to determine whether you have met tax filing o; 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 authonty of Massachusetts General Law,Chapter 62C Section 49A. <br /> The Conuvmnnealth a Massachusetts ` 0 <br /> BARNSTABLE as ���py �/y�,�� DATE <br /> Personally appeared before pre tl above-namedlt�`"C'"t'�''� �v '•'—"'est/ and made oath that the foregoing statement is <br /> true. <br /> A certificate issu in actor Ice with this section shall be in force and effect for four years from the date of issue and shall be renewed <br /> cacli four y ars t after dor g ell business steal:-be cornu tied and shall-lapse alid-be vow unless so renewed—.../��/`l <br /> Signed. L <br /> J EPH L.M ELLI,JR <br /> SEAL Notary Public$$�� <br /> "�anmuasTTS <br /> ionEi�ues�E <br /> OctOW 25,1013 <br />