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Vol <br /> �- fl BUSINESS ,CER'17RICATE # 09__ <br /> ITIL COA9AIOA1WI,'1ILT1-1OFAIASS1ICIIUSG7'7S <br /> TOWN OF AIASII_PI,'E r <br /> • DATE <br /> Expiration Date: December 31, 2013 <br /> fit conformity with the provisions o1Chapter 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 /> � /7v�ui3 aY� <br /> DBAis U dsJf'���f is conducted at <br /> Business Location: <br /> Business Mailing Address: � -le— 1f� �pe�j ?/ <br /> Business Type: �4IA.v i.Z ,�P�UlG(,d Business Telephone: <br /> by the following named persons: _ <br /> FULL NAM/E� RESIDENCE <br /> fi7DlJ <br /> Home Phone: <br /> I certify under the penalties of perjury that 1, to the best of my knowledge and belief, have filed all state tax returns and paid all state <br /> s a Ed corder laws.-�� � <br /> TK9ffKII-e of authorized agent // *Signature of authorized agent <br /> **Social Security Number(Voluntary) <br /> of Federal Identification Number <br /> / �/A9J - / /� In case of emergency <br /> NAME:6 /'75 / �'4aO f TELEPHONE NUMBER: <br /> Alarm Company: - <br /> *This license will not be issued unless this certification is signed by applicant <br /> *"YOU) soclsl security number will be furnished to the Massachu.scits Department of Revenue to deterriine %.whether Vol] have met tax filing or tax <br /> payment obligations. Licensees who fail to correct their non-filing or delinquency will be subiect to license susoension or revocation. This request <br /> is made under the authority of Massachusetts General Law,Chaptcr 62C,Section 49A. <br /> The Comm rn wealth of Massachusetts <br /> 13ARNSTA13LiC ss DATE � <br /> Personally appeared before me the above-named C-rH ISZ"OIPW-N\t-4-10" 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 and and shall be renewed <br /> q <br /> each four years thereafter so long as such business shallSal p�be conducted and shall lapse and be void unless • ;o<••�•E••C9 <br /> � MM, xp•. <br /> S <br /> �'Dtn•. <br /> 5ivned <br /> . .n () � JAN• <br /> rK•l;lttqq <br /> 1 \ lalbli <br /> n'�F � C <br /> SEAL Y�9�rhOFMAS,'P" <br /> T'•••.C� <br /> 101on`Expires: <br /> .qi„nuuu <br />