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BUSINESS CERTIFICATE A0 tF3,- 003 <br /> TOWN OF MASHPEE <br /> Date: rte/ <br /> Expiration Date: I <br /> In conformity with the provisions of Chapter 110, §5 of the Massachusetts General Laws, as amended, the <br /> undersigned hereby declares)that a business under the title of <br /> Business Name/DBA: Chico's tt313 Corporation Name: ( �O <br /> is conducted at Business Location: 8 Market Street Certificate No. 2010-029 `�,1(I►`rJ <br /> Business Type: Apparel Retail <br /> 313 <br /> New [ J Renewal V Commercial [ ] Residential [ ] Email Address: luanne.b <br /> Business Mailing Address: 11215 Metro Parkway Fort Meyers, FL 33966 <br /> Business Telephone: SIS`) Home [ ] Cell [ ] Phone: 508-539-2473 <br /> by the following named persons: <br /> 04 lL-e y/Owrier Name Owner Residence <br /> '� �C SLAs-o�' I UP7c4 {a Y�v1, <br /> I cemerry u uthe penalties of perjury that 1, to th best of my knowledge and belief, have filed all state tax returns and paid <br /> all state taxes as required uritta law. <br /> "Signature of authorize&agent *"Social Security Number <br /> "This license will not be issued unless this certification Is signed by applicant or Federal Identification L—� <br /> Number(Required) <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-flling or delinquency will be subject to license suspension or <br /> revocation. This request Is made under the authority of Chapter 62C,§49A Massachusetts General Laws <br /> S.' d �L TheComntoun,ealth of Massachusetts , I <br /> DATE zi <br /> Personally appeared before me the above-named .KZn T. C' . 'u Qand made oath that the foregoing <br /> statement is true. <br /> A cenifr c issued in accor •e with this section shall be in force and effect for four years from the date of issue and shall be <br /> renewed each Po crus thercalle' o la as such husiness shall be conducted and shell lapse and be void unless so renes V4 / <br /> • Si ed / <br /> Notary Public /i n 1'h-' (,t 1'Kl�jlr�C.G <br /> LUANNE BURKH ER <br /> X-1 Nolaiy Public•Mete of FlariCommission Expires <br /> Conannisslod 854f)77 <br /> My Comm.Exphes Feb 6.2017 <br /> BoAded fbmupb Nati <br /> onal Nota otay Assn, <br />