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BUSINESS CERTIFICATE#,-_�60 _0t <br /> THE COMMONWEALTH OF MASSACHUSETTS v Q <br /> TOWN OF MASHPEE <br /> • DATE � ' � 0 11 <br /> Expiration Date: I D 10L, <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 /> 500.1 qt <br /> Business Name/DBA: n70ehe Pt no, Med,iG Corporation Name: is conducted at <br /> Business Location: 40 S R .0 oSc� (IA0.L, i XI A 0,�k(,45 <br /> Business Mailing Address: Ll0 S �lC t'd k.), Cln ack Mct,.S V Q l-18 Q'�45 <br /> Business Type: SoC.,C k �APlli0. ACtOG`PY11Qrld3usinessTelephone: c0'6' ( 4-g" 89g9 <br /> Home Phone: I'l-4- S al• 3 ra S8 Email Address: rtirnP iT�(CA gl t'1 at' C_':7 rn <br /> by the following named persons: <br /> Owner Name Owner Residence <br /> l.�AnGkA n7oelle ��nQ 4o S. o c1-, CIA. )- Qi ,rae. <br /> �Gr�Sh K.alo �� n°t SAA 0D64 <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 /> ops - 88 - 1n34 <br /> Signature of authorized 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: nt ari SN, l- 'oko_ '? C\P, TELEPHONE NUMBER:j08-S(ob---�310 <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 qC <br /> BARNSTABLE ss DATEKQ>.:�_V <br /> is[rue. c� <br /> Personally appeared before me the above-named s7- _ -'/>s C Sand made oath that the foregoing statement <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 the o g as such business shall be conducted and shall lapse and be void unless so renewed. <br /> Signed <br /> i <br /> Notary Public <br /> SEAL <br /> • 1 W Jacm 1 -10 <br /> CommiA6'MgPnplires:" <br /> COMMONWEALTH a <br /> My Comlubt E+. M <br /> O abr".4l,Mill <br />