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BUSINESS CERTIFICATE# <br /> THE COMMONWEALTH OF MASSACHUSETTS <br /> i TOWN OF MASHPEE <br /> DATE � 1 �U I / <br /> Expiration Date: <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 /> 1 <br /> Business Name/DBA:,(� Corporation Name: is conducted at <br /> 9^S <br /> Business Location: &s Old &CXU zd t2oad M-ap ok, tm oatpNQ <br /> Business Mailing Address: 8 ��d I�1ricww'd Chad " in ' t VY1A Oala49 <br /> Business Type:�JGlf�hi" On��jgn.& BtsinessTelephone:�ig' WN_0101.1h <br /> Home Phone: t'50Fj-14 9? - 019 Email Address: <br /> by the following named persons: <br /> Owner Name Owner Residence <br /> ,�gpoi �nitloG? 8� Old peaC�___� t�3v49 <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 /> nature o uthorized agent "Social Security Number(Voluntary) <br /> or Federal Identification Number <br /> 'This license will not be issued unless this certification is signed by applicant <br /> In case of emergency <br /> NAME: TELEPHONE NUMBER: <br /> Alarm Company: <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 <br /> request is made under the authority of Massachusetts General Law,Chapter 62C,Section 49A <br /> The Commonwealth of Massachusetts BARNSTABLE ss DATE � h I <br /> nW& V <br /> Personally appeared before me the above-named —I E 1%)V(r�2 ` and made oath that the foregoing statement <br /> is true. <br /> A certificate issued in accordance with this section shall be in force and effect for four years 6utn the date of issue and shall be renewed <br /> each four years thereafter so long as such business shall be conducted and shall lapse and be void unless so renewed. <br /> Signed <br /> Notary Public <br /> SEAL, <br /> • Commission Expires: <br /> JosEPM L. <br /> cotrol"nLTM as t7it <br />