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BUSINESS CERTIFICATE�y' 0 94 <br /> TOWN OF MASHPEE <br /> Date: `LZ Il <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: 5 - W <br /> is conducted at Business Location: C-21 P kvt L <br /> Business Type: � ^ �f:) r,Q �71 f , �1 A �aAF lv/ s Ar /�/! S 'OAC <br /> New[Renewal ( ]--Commercial [ ] Residential [ ] Email Address: ('a k t<)2tQT—Cc-� � <br /> Business Mailing Address: oad (nn) Ven <br /> Business Telephone: .567-IO—K-L]2Home [Cell ( ] Phone: <br /> by the following named persons: <br /> Owner Name Owner Residence <br /> Yris bkf ck aI Vtilea Cjt,) +Juv-ev\_ JDr <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 stats requiredur — <br /> 'Signature of authorized agent "*Social Security Number (Voluntary) <br /> "Th is license will not be issued unless this certification is signed by applicant or Federal Identification Number <br /> In case ofnemergency`` <br /> NAME: 11 Iw)nael L_Lalck� TELEPHONE NUMBER: 5dg- 737-62gD <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 /> Tire Commonwealth of Massachusetts <br /> BARNSTABLE, ss DATE <br /> Personally appeared before me the above-named 2t64& 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 years from the date or issue and shall be <br /> renewed each fopra'cor her: Ira shall be conducted and sh,dl lapse n be void unless sore esvcd. <br /> • Si net(�fiil/ A Notary Public <br /> g <br /> Commissi E it <br /> ,JR. <br /> NOTARY PUBLIC <br /> COMMONWEALTH OF MASSACHUSETTS <br /> IFMY COW.Expires OCL t6,2020 <br />