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} <br /> BUSINESS CERTIFICATE <br /> TOWN OF MASHPEE �{ <br /> Date: <br /> • Expiration Date: S 3 f t <br /> In conformity with the provisions of Chapter one hundred and ten, Section five of the General Laws, as <br /> amended, the undersigned hereby declare(s)that a business under the title of <br /> Corporation Name: SI, lcYr Business Name/DBA: <br /> is conducted at Business Location: �1 sihrP .c) r_ o,c*L . A <br /> Business Type: O % <br /> New[Renewal [ [ --Commercial dResidential [ ] Email Address: e�St. ��eC�bn. <br /> 1 <br /> Btisiness Mailing Address: J` LAD l�h . 61 FP, Ocke ._04on A, . MA o231iO <br /> Business Telephone: Home [ [ Cell Ki Phone: <br /> by the following named persons: <br /> Owner Name Owner Residence �� <br /> �r:Yn hin `I��rren 540 oJy�A-e_ QI{(5 �") P( rno�f�.I.-A Oa3� <br /> Ask <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 <br /> all state taxes as required under law. <br /> -17 <br /> *Signature of authorized ag t **Social Security Number (Voluntary) <br /> *This license will not be issued unless this certification is signed y applicant or Federal Identification Number <br /> r e <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 <br /> filing or tax payment obligations. Licensees who fail to correct their non-filing or delinquency will be subject to license suspension or <br /> revocation. This request is made under the authority of Massachusetts General Law,Chapter 62C,Section 49A. <br /> z+ The Commonwealth of Massachusetts <br /> BARNSTABLE, ss2 I DATE S 'y <br /> U_4_ " <br /> Personally appeared before me the above-named ~' and made oath that the foregoing <br /> statement is true. <br /> A certificate issued in accordance with this section shall be in force and effect for fow-yeaq from the date of issue and shall be <br /> renewed each four years—thereafter so long as such business shall be conducted and shall lapselbe unless so renewed. <br /> igned // _ Notary PublicNoWy N�lic <br /> Commission Elb1�t01aMFItL1NOF MASSACNM <br /> JIM3, <br />