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BUSINESS CERTIFICATE 161 d� <br /> TOWN OF MASHPEE <br /> Date: <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: uslness Name/DBA: � <br /> is conducted at Business Location: <br /> BusinessType: /.� z <br /> New�nenewal [ ] --Commercial [ ] Residential [ ] Email Address:��(/G <br /> Business Mailing Address: <br /> Business Telephone�a�6I77%�T'Pi 7Home [—}tell [ ] Phone: <br /> by the following named persons: <br /> Owner Name Owner Residence <br /> 1 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 state taxes as required under. law. <br /> �ignaTurf;`cf authorized agent "Social Security Number (Voluntary) <br /> "This license will not be issued unless this ceruftcatio issigned by applicant or Federa l Identification Number <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 Massachusetts General Law,Chapter 62C,Section 49A. <br /> The Cnmmomvenllh of Massachusetts <br /> BARNSTABLE, ss DATE <br /> Personally appeared before me the above-name d 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 four yews from the date or issue and shall be <br /> renewed each four years thereafter so long its such burin s shall he conducted and shall lapse and void unless sq newed. <br /> Notary Public - yL� 11 <br /> Commission Ex <br /> J-"..ill i (,otEgailt <br /> �, i.' .7,1ri k:lff8/0.M OP IAASSACIA7SETT3 <br /> ' i.:;v:aifft.explrea Oct 16,2020 <br /> J <br />