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BUSINESS CERTIFICATE '30 15-003 <br /> TOWN OF MASHPEE / <br /> . Date: �� / � A <br /> Expiration Date: 1 /31 A S <br /> In conformity with the provisions of Chapter 110, §5 of the Massachusetts General Laws, as amended, the <br /> undersigned hereby declare(s)that a business under the title of <br /> Business Name/DBA: Chico's#313 Corporation Name: <br /> is conducted at Business Location: 8 Market Street Certificate No. 2010-029 <br /> Business Type: Apparel Retail <br /> New [ ] Renewal [VJApCommercial [ ] Residential [ ] Email Address: luanne.burkholder@chicos.com <br /> Business Mailing Address: 11215 Metro Parkway Fort Meyers, FL 33966 <br /> Business Telephone: Home [ ] Cell [ ] Phone: 508-539-2473 <br /> by the following!named persons: <br /> D. IL,q y/ Owner Name Owner Residence <br /> LANA-Col S 1' AS, 1nL 1 l a- K yy\\a •-w P <br /> ScAA.0SCI"`� UP-TC4 Y�vS, PL ;6L <br /> I cernry uhuer the penalties of perjury that 1, to the best of my knowledge and belief, have filed all state tax returns and paid <br /> all statetaxes as required YrrzlUr✓,aw. <br /> --- --- - - - - — s�a 3YC-1'A5 <br /> `Signature of authorized-acnt "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-filing 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 /> Sa The Commonwealth of Massachusetts 1I <br /> DATE <br /> Personally appeared before me the above-named S and made oath that the foregoing <br /> statement is true. <br /> A certifi e issued in actor a with this section shall be in force and effect for four years from the date of issue and shall be <br /> renewed each fo ears thereafte o to as such business shall be conducted and shall lapse and be void unless so rene <br /> Si ed rP / Notary Public .Cl1 Ge j1—e � Y�IiC-(J/pe(.G <br /> al1ANNE BURKRo R <br /> - <br /> Rota( :Public-State 01110rida Commission Expires <br /> My Comm.Expltes F&67,2017 <br /> '•o`;�. tommis'siod N EE 854027 <br /> '%E8,1"`,5°P'� Bonded dhroupRNallonal Nolaly Assn. <br />