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�P to 3 ,5-1a <br /> BUSINESS CERTIFICATE__LL�_ <br /> TOWN OF MASHPEE <br /> • Date: s Si r ap iy <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 / l <br /> Name: Ther��� S/K• Business/INam�te/DBA: �CL�C�TJ 44"- <br /> Corporation r� <br /> is conducted at Business Location: .?3 �e�f'e S� /'40tL 2( 1,Y6-Z //Jp3h g " 4 Zbyg <br /> Business Type: A/ o 3 lekil 010MLI)i <br /> New[ ] Renewal V-Commercial [ ]-Residential [ ] Email Address: To/Lb�3- Lo/Jl <br /> Business Mailing Address: 173 6!a/ 6#&J All t Y!/!7 LW O.ZOV <br /> Business Telephone: `Io I-7Y/" Vd5ff Home ( ]Cell [ ] Phone: <br /> by the following named persons: <br /> Owner Name d Owner Residence <br /> C 1 <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 statepgieas required under law. <br /> *Sig6t6re of authorized ageKt) "Social Security Number(Voluntary) <br /> 'ibis license will not be Issued unless this certification is signed by applicant or Federal Identification Number <br /> In case of emergency <br /> NAME: Jeow12 6/1L`2 2rd50/I TELEPHONE NUMBER:l1O�' 77_5_'P& 9 <br /> Alarm Company: V7l//J/26/ �9///ii:L1 <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 subsea 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 <br />� 3 Q? oAn+ 'klVTUrC- . DATE <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 f and effect for four years from the date of issue and shall be <br /> renewed each four years thereafter so long as such business shall be ucted and shall lapse and be void unless so renewed. <br /> Signed Notary Public <br /> Commission Expires <br />