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' BUSINESS CERTIFICAT <br /> �- (A <br /> TOWN OF MASHPEE <br /> Date: SII I <br /> Expiration Date: T/ 3011 g, <br /> In conformity with the provisions of Chapter 110, §S of the Massachusetts General Laws, as amended, the <br /> undersigned hereby declare(s) that sin�Nnde�he ti le of <br /> Business Name/DBA: s n/e� a GevD />7 ora I n Name: (cCorporation_Name)) <br /> is conducted at Business Location: I Ff«Street » ((Stret Name)) Certificate No. ((Certificate-))s& W,� <br /> Business Type: aType_of_Business» <br /> New [ ] Renewal [ ] Commercial [ ] Res dentia) [ ] Email Address: <br /> ((Email_A/dddressi) <br /> Business Mailing Address: «Ml firfi A rss» aMalT_ of Vih�Stateit t<IVlailing_ ip» 1 <br /> Business Telephone: Bus Telephone)) Home [ ] Cell <br /> �[1JC] Phone: ((Owner_Telephone)) <br /> IOU <br /> by the following named perYdyts��� <br /> Owner Name Owner Residence <br /> ((Owner Name)) ((Owner Residence Street)) (Owner Resideric TSZ)) <br /> Second Owner F Name» ((Second Owner Name»«Second wne Ad r ss» <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 <br /> IS' <br /> to taxes as re fired under law. <br /> *Si nature authorized agen **Social Security Number <br /> *This license II not be issued unless th 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 subject to license suspension or <br /> revocation. This request is made under the authority of Chapter 62C,4 49A Massachusetts General Laws , <br /> The Conaaomveahhh of Massachusetts <br /> BARNSTABLE: ss DAT,�E} Ani Q Y 2011 <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 farce and effect for four years from the date of issue and shall be <br /> renewed each f r vcairs therea ie so long a. such business shall be conducted and shall lapse and b �o un less so renewed. <br /> Sign NOeb0n8d Da vf.-9,C7ja�— <br /> e <br /> NOTARY PUBLIC <br /> CofiRffdmli Mfl 5FMWAachuszne <br /> My Commission Expires July 29,2016 <br />