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BUSINESS CERTIFICATE#tVc_ <br /> THE COMMONWEALTH OF MASSACHUSETTS <br /> TOWN OF MASHPEE <br /> • DATE 1 -12- / O <br /> Expiration Date: December 31, 2%1'-J '— <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 /> w 571' Vy R � � VI/I ,e9 'Q _/QDBA is conducted at <br /> Business Location:) e Ul/ C-e G1 e Anta a OJ/ <br /> Business Mailing Address: I Q Ea CS W Q 2 i� tl <br /> Business Type: Business Telephone: W 17- <br /> by the following named persons: <br /> FUhL NAME ESIDEN E <br /> Wu� 2 e n F, r e s �"7 e R Y l7 IZ e a(� IDEN e R R o a d <br /> Home Phone: SU 3 9 13 7 <br /> I 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 /> taxes as required under law. <br /> Oignature of authorized agent *Signature of authorized agent <br /> ,e�1�v J 7—/ C E2 997 <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 he 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 <br /> Personally appeared before me the above-named IU �2 1 !e�S 7Vrr= 2, 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 so long as such businessshallbe conducted and shall lapse and be void unless so renewed. <br /> Signe ;k:'— -� G�/ Y_ <br /> S" JVQQW&J7 -HELU,JR <br /> • ° k <br /> SEAL- COMMONWEALTH <br /> OF GWS <br /> camn;i8nion F: <br /> Corrmjtbl�l 'es: <br />