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'TWIN, <br /> TOWN OF MASHPEE <br /> CStatement of Discontinuance,Change of Residence, Change of Location of Business, <br /> L O" <br /> Withdrawal,or Deceased from Business or Partnership, Changeof Business Name.or Owner Name <br /> ^ <br /> 6"'I wo- i a , (20/ 5, <br /> DATE <br /> The Town is desirous of going"Green" as much as possible.To that end,please include your email address. <br /> Email Address: <br /> Discontinuance <br /> In conformity with the provisions of Chapter one hundred and ten, section five, of the General <br /> Laws, as amended, the undersigned hereby declare(s) that I/We has (have) this day discontinued (retired <br /> from) (withdrawn from) the business of <br /> conducted at <br /> STREET <br /> SIGNATURE <br /> Change of Location of Business <br /> I hereby state that the location of the business/my residence as it appears on the Business Certificate filed <br /> on I 1p kk/ has been changed to <br /> • ame of Usines ^ <br /> l <br /> SIGNATURE <br /> Change of Name of Business or Owner <br /> I hereby state that the name of the business or the owner as it appears on the Business Certificate has <br /> been changed from Mia � r'1n 11 <br /> to od ° <br /> SIGNATURE <br /> Notary av S <br /> Barnstable ss. <br /> Date <br /> Personally appeared before me the above named 14 all l Q Vaa and made oath <br /> that the foregoing statements are true. <br /> • - Name-Notary Public <br /> Commission Expires <br /> Its Deborah Dami <br /> ' NOTARY PUBLIC <br /> OrigfomdDiscontinuance Commonwealth of Massachusetts <br /> My commission Expires July 29.2016 <br />