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// BUSINESS CERTIFICATE <br /> .TOWN.OF MASHPEE <br /> • Date: /7 �/ 3 <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 declares) that a business under the title of r <br /> Corporation Name: k' v1nc,-- Business Name/DBA: <br /> is conducted at Business Location: I 1 ��! ✓e- � v 1.2 /� ✓✓lam�—t ofQ m 4 <br /> Business Type: ur��`7��a✓�tel/ Gym y <br /> New�enewal [ ] - Commercial [ ] Residential [ ] Email Address: <br /> Cow c��h <br /> Business Mailing Address: ( vt <br /> Business Telephone: CO2 217 —SC2�YHome [ ] Cell [ ] Phone:( A <br /> by the following named persons: <br /> Owner Name Owner Residence <br /> • �ayic�_ ( o`Z L0Q�-Q lin r <br /> 41 ae <br /> �f�.t^-vl .� 6 <br /> boZ3 Ca_ <br /> CD <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 <br /> all state taxes as required under law. <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: 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 subiect 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 1 DATE <br /> kPersonally appeared before me the above-named Ir 4 A r_t(�4 4A VA,,* and made oath that the foregoing <br /> •statement is true. <br /> JOSEPFI C. <br /> A certificate issued in accordance with this section shall be in force and effect r ears frohall be <br /> renewed a ch four years thereaft s long as such business shall be conducted and shall I <br /> Signe Notary P <br /> Commission Exoires <br />