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' BUSINESS CERTIFICATE#t�Ara <br /> THE COMMONWEALTH OF MASSACHUSETTS <br /> TOWN OF MASHPEE <br /> DATE /0 <br /> Expiration Date: [i/tx <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 -l'� <br /> DBA��, L.t(?Gf� 7' y- is conducted at <br /> i <br /> Business Location: :may M _ P r flIH QaLpi-4q <br /> Business Mailing Address: 3D ')D'/ :SQA 016 < ane WA C)n 40f <br /> Business Type: L k; 1 r4ren'` Business Telephone: _SOB- 414- I gaSi `181- 5'1n7o 1 <br /> Home Phone: <br /> by the following named persons: <br /> FULL NAME RESIDENCE <br /> r�G-�t�c�-G�- IZvdr��cta;S i I �(-'4,sS 12.1 Y�C�p�; rnr�- oarP49 <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 /> 06 A .G,,.t to A— <br /> ignamre of authorized agent LJ *Signature of authorized agent <br /> -1C� C> 3 I <br /> **Social Security Number(Voluntary) <br /> or Federal Identification Number <br /> In case of emergency <br /> NAME: TELEPHONE NUMBER: <br /> Alarm Company: <br /> I <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 subject to license suspension or revocation. This request <br /> is made under the authority of Massachusetts General Law,Chapter 62C,Section 49A. <br /> The Comaeonweahh of Massachusetts BARNSTABLE ss nn �f DATE � O <br /> Personally appeared before me the above-named_ 745 AV—A 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 is such business shall be conducted and shall lapse and be void unless so renewed. <br /> Signed <br /> t--+cin s fly . <br /> • SEAL JOSEPH L` A UNE LI,JR <br /> Kota:, .Ghc <br /> �� pr��s�l�xpires: <br /> October 25.2019• <br />