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v <br /> BUSINESS CERTIFICATE <br /> TOWN OF MASHPEE q /� /� <br /> Date: f-tl/n 1�''f')T��� <br /> Expiration Date: 3Q 62I[9 <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 titllee��}of <br /> Business Name/DBA: Q/1 (J mpl2�oration Name: <br /> is conducted at Business Location: �C�[I r2-i'YY l A\4r _ Certificate No. <br /> Business Type: <br /> New [] Renewal commercial [] Residential (Email Address SCj(Q ODv hP/i/ �o.� lQ/LrMC�I 1. C-6w, <br /> Business Mailing Address: �S �t1 I� l.�rGlfL <br /> Business Telephone: 1;0 D- Home [ ] Cell [ ] Phone: <br /> by the following named persons: <br /> Owner Name Owner Residence <br /> lRo61� ` - Vymmain✓ q-) —CAOn&O C'L\r-clo- <br /> 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 mired under w. <br /> " e , �Y - �2-4 Y� <br /> 'Signature of a'uthorized agent "Social Security Number <br /> *This license will not be issued unless this certification is signed by applicant or Federal Identification <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 /> The ComnrontvealNt of Massachusetts <br /> BARNSTABLE: ss DATE <br /> Personally appeared before me the above-named 6d��. rr.+ 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 years from the date of issue and shall be <br /> .enewed each four vears thereafter s ng as such business shall be conducted and shall lapse andryi,�1/,,oid unless s/o//�renew <br /> SignedZV/,f Notary Public Y JXfW f7(!K. <br /> Deborah Dami <br /> o NOTARY Cgr7ytj6on Expires <br /> Commonwealth ofPMLlasssaachusetts <br /> My Commission Expires July 29,2016 <br />