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,r't <br /> BUSINESS CERTIFICATE# <br /> THE COMMON641EAL TFT OF MASSA CHUSETT S <br /> TON?V OF MASHPEE <br /> DATE- , /�/ lam_ <br /> • Expiration Date: ( (o /S <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 /> Business Name/Dl3A:Nldt'tr bec:Qnr (nA Cor�pootration Name: is conducted at <br /> Business Location: �n.� �+ IYIGS�Loer <br /> Business Mailing Address: <br /> Business Type: \n,.v�.��i � BusinessTelephonc: <br /> c� 7 <br /> Home Phone: Email Address: 54P t1n 6;)V W-Y i ) <br /> by the following named persons: <br /> Owner Name Owner Residence <br /> .ta,1 �tvTb� cllZCc r r/�n K—, 1W <br /> C2 n��, utllo t 1YLfl 0a6;7Q <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 as re aired under law. <br /> •nature of authorize .gent *`Social ecurity 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 /> *"four social security number will be furnished to the Massachusotls Department of Revenue to determine whether you have met tax filing or tax <br /> paynrent 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 afMassaclursetts _ <br /> BA12NS'fA.13LE ss DATE <br /> Personally appeared before ns the above-mmiied S'S'Lr/LJTI �—. FAG[nl 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 yearstherea Lcr so longong s siness shall be conducted and shall lapse and be void unless so renewed. <br /> Signed l <br /> • SEAL JOANNE M. iblic Votary Public <br /> VyA �' <br /> Notary Public (,3 1-7.p� . <br /> Commonwealth of Massachusetts Co ,mission Expires: <br /> Commission Expires January 13,2017 <br />