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BUSaVE.SS CERTIFICATE ftp_ <br /> • THE COMMONWEALTH OF MASSACHUSETTS <br /> TOWN OF MASHPEE <br /> DATE � 3� /d <br /> Expiration Date: AI <br /> els <br /> In conformity with the provisions of Chapter one hundred and ten, Section five of the General Laws, as amen ed <br /> undersigned <br /> 11 hereby declare(s)that a business under the title of d(', ` I \,, . <br /> C'�uslatr'e L`C- DBA C- -kIrL ( l A (fir V Mel i a�conducted at <br /> Business Location: 4S. I1,O(`Ca�.f_3 ��. J�I��tS 1��S? <br /> Business Mailing Address: ((2 1w Lam' <br /> Business Type: 9P A � XLVA Sp&eial� Business Telephone: <br /> by the following named persons: <br /> FULL AME RESIDENCE <br /> AA c/• �P 1rG2 v�8 iz p � g04 <br /> Home Phone: <b 2_rs�_qS <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 /> taxes r u' ed un wr—^- <br /> • I'qW �� . <br /> 'Signature of au oriz'edd agentg "Signature of authorized agent <br /> �/.d ';'6 — Y'S G ptr/-2-- <br /> "Social Security Number(Voluntary) <br /> or Federal Identification Number <br /> In case of emergency <br /> NAME: 'N <br /> 'NA-'e Zp t(YC]I�O�l TELEPHONE NUMBER: Sa$ u <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 be subiect 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 MoasaehrtseUs <br /> BARNSTABLE ss DATE <br /> Personally appeared before me the above-named D ��1� �� �'[►q rS t and made oath that the foregoing statement is <br /> we. <br /> A certificate issued in accordance with this section shall be in force and effect for four yearsKm the date of issue and shall be renewed <br /> each four y succi ,UP ss shall be conducted and shall lapse and be void unles so ewed. <br /> Signed <br /> • Notary Public <br /> j SEAL <br /> omnus� �es: <br /> Cpt1011WFALfIt OF IlRftitG <br /> w rtiow <br /> aofr <br />