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Tri l! <br /> • BUSINESS CERTIFICATE/ f-0 <br /> TOWN OF MASHPEE <br /> Date: /y <br /> Expiration Date: _ rX 26jcf' <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) tat a business under the title of rte, . <br /> Corporation Name: ( t in� Name/DB[A: V L,:_ I <br /> is conducted at Business Loca�(tiiion: 0 ' 1 e v <br /> Business Type: P+O.NSi lj <br /> New[Renewal [ ] --Commercial [ ] Residential [ ] Email Address: <br /> lI( <br /> Business Mailing Address: l / [r 1 'Ll Sle yi 1 —�7 <br /> Business Telephone-an ` / Home [ ]Cell [ ] Phone: i7 13-/` <br /> I <br /> by the following named persons: <br /> Owner Resid <br /> Owner NarR.q ce <br /> ] L 6f/0 lam/ Iti4 J i1S <br /> I • <br /> 0260 <br /> I <br /> 1 certify under the penalties of perjury that I, to the best army knowledge and belief. have filed all state tax returns and paid <br /> all state taxes as required under law. <br /> `fl 1_rl 139.3 <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 /> i <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-tiling or delinquency will be su6ct to license suspension or <br /> revocation. This request is made under the authority of Massachusetts General Law,Chapter 62C,Section 49A. <br /> The Connuonrvenllh of MassachusetA'' r I <br /> BARNSTABLE, ss - ^''/� DATE <br /> Personally appeared before me the above-named�L,t L I42— and made oath that the foregoing <br /> statement is true. <br /> A certi ficate is lie in ac with this.ection shall be in force and effect for four,Years li-om the slate or issue and shall be <br /> rcnewcd ca our year ter so long s such In s iness shall he conducted and shall lapse at�l�b\e,,oitI unless sQn react d. I , <br /> Signed Notary Public �dlJ"�Oil LL X c—T <br /> o(aboOAMn Expires <br /> Deb <br /> n� NOTAR LlC ealo 0, chusetts <br /> MyOmmonw <br /> Com isslon wilesJuly 29,2016 <br />