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BUSINESS CERTIFICATE <br /> TOWN OF MASHPEE <br /> Date: <br /> Expiration Date: <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: !! Business Name/DBA:?o A <br /> fr~ Fa✓wi <br /> is conducted at Business Location: 6-clZ f5y, . Ott &L V ieeed rib df PF f At) 62Cot4 `[ <br /> Business Type: Fn r.k S Fa..d <br /> New [✓] Renewal [ J --Commercial [ ] Residential [ ] Email Address: <br /> Business Mailing Address: sl.n rew go c1 by tue, &&4- Fcdm. o ff^ M A u Zs-3 <br /> Business Telephone: Home [ ] Cell [ yj Phone: Bt is qKB 0490 <br /> by the following named persons: <br /> Owner Name Owner Residence <br /> imn �ueut a(6; <br /> 5lu62W. r D. . <br /> iI UA,)'* Ila- 625-3,G <br /> WI 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 /> 119- U.-_ ool 7k 2?A9 <br /> *Signature of authorized agent **Social Security Number (Voluntary) <br /> *This license will not be issued unless this certification is signed by applicant or Federal Identification Number <br /> In case of emergency <br /> NAME: .i&A& _Sajmbyt TELEPHONE NUMBER: 5e R 457 (6670 <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 /> The Commonwealth of Massachusetts <br /> BARNSTABLE, ss (� DATE 3 <br /> Personally appeared before me the above-named Be Us-v*, I-A XA- C^ d 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 four ye s om the date of issue and shall be <br /> renewed each' ur ytearather er so long as such business shall be conducted and shall lapse and be�v i unless so renewed. <br /> igned \JJ�r Deb. (1 0.jy Public <br /> NOTARY PUK C <br /> 'COWdngMVIM 01Expires <br /> Yy Cattvnktbtt Etmgt�?o,2018 <br />