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License will not be issued unless this certification clause is signed. <br /> I certify, under the penalties of perjury that, to the best of my knowledge and belief, I have filed all state <br /> tax returns and paid all state and local taxes as required by law. <br /> Signature of Individual <br /> or Corporate Name (Mandatory): �i�,�,� �'« arc Fs c c— Date: J L7 h <br /> v <br /> By Corporate Officer: C�1,�f'� �able) SSN/FEIN:_ <br /> (Mandatory if a <br /> *Your Social Security Number or Federal Identification Number will be furnished to the Massachusetts <br /> Department of Revenue (DOR) to determine whether you have met tax filing or tax payment obligations. <br /> Licensees failing to correct their non-filing or delinquency will be subject to license suspension or <br /> revocation. This request is made under the authority of M.G.L. c. 62C, §49A. . <br /> Page 1 <br />