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It <br /> BUSINESS CERTIFICATE D l <br /> TOWN OF MASHPEE (� //�► <br /> • Date: MQfG'1 IY�� �p�� <br /> Expiration Date: �(S'Y) <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: Church Pies of Cape Cod Corporation Name: <br /> i <br /> is conducted at Business Location: 259 Shore Drive, Unit#6 Certificate No. 2011-039 <br /> Business Type: Non-Profit Food Raising <br /> New [ ] Renewal [ ] Commercial [ ] Residential [ ] Email Address: janddchase@aol.com <br /> Business Mailing Address: PO Box 1796 Mashpee, MA 02649 <br /> Business Telephone: 508-274-7387 Home [ ] Cell [ ] Phone: <br /> by the following named persons: <br /> Owner Name Owner Residence <br /> David Chase Qo'((p✓1S <br /> 01 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 state taxes as-required under li <br /> *Signature of authorized 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 subiect to license suspension or <br /> revocation. This request is made under the authority of Chapter 62C,§49A Massachusetts General Laws <br /> The Commonwealth of Massachusetts t <br /> BARNSTABLE: ss DATE A /�i 20 l S <br /> Personally appeared before me the above-named 19 Vsv �"�' Cf/�S� 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 yearb.from the date of issue and shall be <br /> • �V 7 `arenewed eac ur--years t erree�aafter so g a such business shall be conducted and shall lapse and be oid unless so renewed. <br /> Signed 'n'_ Notary Public <br /> . <br /> s Deborah Dami commission Expires <br /> NOTARY PUBLIC <br /> Commonwealth of Massachusetts <br /> My Commission Expires July 29,2016 <br />