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1/ BUSINESS CERTIFICATE <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: Business Name],//D�B�A:: (�°/ ���nSC� `�a/]'l��'r <br /> is conducted at Business Location: �(( I Il V��Q+ II X��I Mtn / (a' 04) (47 <br /> Business Type: ar-7k S [u lJ <br /> New ] Renewal [ ] —Commerlciial [ ] Residential ( <br /> ] EmailAddress: <br /> Business Mailing Address: <br /> Business Telephone: — U/��—� �(H'�me Phone: <br /> by the following named persons: <br /> Owner�g Owner Residence <br /> 1 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 state taxes as required under law. <br /> 'Signature of ut d age "Social Security Number(Voluntary) <br /> *This license wil etb ess this certification is signed by applicant or Federal Identification Number <br /> In case of emergen V t� <br /> NAME: \ V 03� 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 Commonweallh ofMassaehuseds <br /> BARNSTABLE, ss DATE Y `� <br /> Personally appeared before me the above-named �a t� Q cfy"1� and 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 ea from the date of issue and shall be <br /> renewed each fou ars t r so long as such business shall be conducted and shall lapse and be r bid unless so renewed. <br /> �Igned N <br /> JMuk-.%Ua� <br /> MAUU <br /> Co Ai <br /> 5 <br />