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v <br /> BUSINESS CERTIFICATE <br /> TOWN OF MASHIPEE <br /> Date: 94.�2L.1i.4 <br /> Expiration Date: Y-90 - gp i Y <br /> In conformity with the provisions of .Chapter 110, 45 of the Massachusetts General Laws, as amended, the <br /> undersigned hereby declare(s) that a business under the title of <br /> Business Name/DBA: aBusiness_NameDBA» Corporation Name: aCorporation_Name» <br /> is conducted at Business Location: «Street_» «Street_Name» Certificate No. «Certificate_» <br /> Business Type: aType_of_Business» <br /> New [ ] Renewal N/<Commercial [ ] Residential [ ] Email Address: «Email_Address» <br /> Business Mailing Address: «Mailing_Address» aMailing_Town», «Mailing_State» aMailing_Zip» <br /> Business Telephone: ((Bus Telephone» Home [ ] Cell [ ] Phone: aOwner_Telephone» <br /> 8-4`T7-P 2z I S00-4.77-O 221 <br /> by the following named persons: <br /> Owner Name Owner Residence <br /> Wwner�Namer ((Owner Residence Street)) ((Owner Residence TSZ» <br /> S( econd Ownerr F Name)) «Second Owner L Name»«Second Owner Address)) <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 stat taxes as Uired under law. <br /> Ol4-.391 8101 <br /> *Signature of authorize agent "*Social Security Number <br /> "This license will not be issu unless this certification is signed by applicant or Federal Identification <br /> Number(Required) <br /> In case of emergency <br /> NAME: o ech TELEPHONE NUMBER: "ma-Z'1� -�EI� <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 Commonwealth of Massachusetts <br /> BARNSTABLE: ss DATE y-aa aott� <br /> i <br /> Personally appeared before me the above-named l�t PYG Y-A (r� 9 e,1�_ and made oath that the foregoing atement is true. _ <br /> A cep jficate slued in accordance with this section shall be in force and effect for four years from the date of issue and shall be <br /> renewed each our y ars th ea Rer so long as such business shall be conducted and shall lapse <br /> rand <br /> /bbee void L ss sorenew(e\d�.' <br /> ary Public ' 1 "lau- GSM )AJ�'tl - <br /> Signed tary Public <br /> Margtvet C.Santos <br /> Commonlje mof Maswchasefts C mission Expires <br /> �My Commission'Expires.on Sept.22,2017 <br />