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1311SINESS Cl'sR't'IFICA'1'E# 09 C iv <br /> lZ/F COMMONHILALT H OF MASSACLTUSLTI'S <br /> 7'0611A'OF MASIJPEL <br /> � DATE_ <br /> Expiration Date: DeCe/1'lber 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 dec��hue(s) that a business under the title of �/ <br /> �AoJ %bY AA-S C9 - DBA S U16C_ p2C l X �2COrJ�S is conducted at <br /> Business Location: ( t W e-p'?'Orla` 5&" 1 N 't- W al11p-art t M qCr <br /> Business Mailing Address: it t'_3 R-69(t, 1h. �k4 SLIP-Q 1 t,(14 e' y9' <br /> -Rusiness'I'ype: mole 'praAri� r Business Telephone: !;"23V X17? — FOS -- - <br /> by the following named persons: <br /> FULL NAME RESIDENCE <br /> V_Ld\I 1 �. iN1�,s cdii- iVC) kA_5t ,' V, m bab4q <br /> I 011ie Phone: <br /> I tify der Ire jrallies of perjury that I, to the best of my larowledge and belief, have filed all state tax returns and paid all state <br /> I uir u dl r law, <br /> na o t ed agent *Signature of authorized agent <br /> "Social Security Number(Voluntary) <br /> mFederal 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 Deparunent of fiev'enue to deteruine whether you have met tax filing or lax <br /> payment obligations. Licensees who fail to correct thch non-filing a'delinquency will be subject to license suspension m'revocation. This request <br /> is made under the authority of Massachusetts General Law,Chapter 62C,Section 49A. <br /> The Commonwealth ol'Ulos'snchuseffs <br /> BARNSTABLE ss DATE :51(7 <br /> 'ersonall apt eared before lire the above-named and made oath that the foregoing statement is <br /> time. <br /> A rtifte e i sue in accordance with this section shall be in force and effect for four years Gom the date of issue and shall be renewed <br /> each fow ear tiler dte so a as such business shall be conducted and shall lapse and be void unless so renewed. <br /> Signed <br /> -11111011 <br /> =MONWEALTH <br /> SEAL Uj' <br /> Expires: <br />