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BUSINESS CERTIFICATE _ <br /> TOWN OF MASHPEE <br /> Date: olz/� <br /> Expiration Date: AiG��� <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 cc,, <br /> Corporation Name: Business Name/DBA: L U�� <br /> is conducted at Business Location: I4�� Ire s �50�1 <br /> �. G1 lL)n <br /> Business <br /> New(A Renewal [ ]—Commercial [ ] Residential [ ] Email Address: <br /> Business Mailing Address: <br /> Business Telephone: Home [ ] Cell [ ] Phone: — <br /> by the following named persons: I $(4 <br /> Owner Name Owner Residence <br /> 0I 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 s��taxes as r ired under law. <br /> .lii����� atm - 51op%98' <br /> Signature f authorized agent "Social Security Number4*ltt tE ) <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 /> "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 Commonwealth of Massachusetts � QQ ,r <br /> BARNSTABLE, ss DATE P�CLo'C/rl lie,, 2B/� <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 force and effect for four year om the date of issue and shall be <br /> renewed eac four years themr so long as such business shall be conducted and: lapse and be i unless so renewed. <br /> igned. Notary Public r <br /> Deborah Dami commission Expires <br /> o NOTARY PUBLIC <br /> Commonwealth of Massachusetts <br /> My Commission Expires July 29,2016 <br />