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BUSINESS CERTIFICATE ] 3 <br /> TOWN OF MASHPEE <br /> • Date: Yloe,,w be, tF . ac 14 <br /> Expiration Date: (41 v.bpr 3'draol <br /> In conformity with the provisions of Chapter 110, §5 of the Massachusetts General Laws, as amended, the <br /> undersigned hereby declare(s)that a business under the title of <br /> Business Name/DBA: Bayview Optometrics Corporation Name: L&D Eye Associates <br /> is conducted at Business Location: 9 Market Street Certificate No. 2010-129 <br /> Business Type: O ometric Practice <br /> New [ ] Renewal [ Commercial [ ] Residential [ ] Email Address: info@bayviewoptmetrics.com <br /> Business Mailing Address: PO Box 1410 Mashpee, MA 02649 <br /> Business Telephone: 508-477-7423 Home [ ] Cell [ ] Phone: 508-477-7423 <br /> by the following named persons: <br /> Owner Name Owner Residence <br /> Robin Genden 31 Brambush Drive Forestdale MA 02644 <br /> Anklan Leavitt 231 Ross Lane <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 /> del y6;-3fl <br /> *Signature of authorized agent **Social Security Number <br /> -This license will not be issued unless this certification is signed by applicant or Federal Identification <br /> Number(Required) <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 Chapter 62C,§49A Massachusetts General Laws <br /> The Commoniveafth of Massachusetts <br /> BARNSTABLE: ss / DATE Y,o u-ey%1 v� l Sri )0 t y <br /> Personally appeared before me the above-named l� n C&r.'Je✓1 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 four years from the date of issue and shall be <br /> enewed each four years thereafter so long as such business shall be conducted and shall la be void unless so renewed. <br /> Signed Notary Public - <br /> Ejha�g;r�ty& SanOrlwealth of MassaciuuEtts Commission Expiresssion Exp res on Sep: ?2,2017 <br />