5 HAYWARD STREET - BUILDING INSPECTION 5 Hayward St. _1
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Pit
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DATE FILED y ') Type: a— New
Expiration Date1-a_ ° .� C2 Renewal, no change
Number ❑ Renewal with change
In conformity with the provisions of Chapter one hundred and ten, Section five of the Massachusetts General
Laws, as amended, the undersigned hereby declare(s) that a business is conducted under the title of:
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at. wA6C D_S%- S�VLe
typeh�rcinrcc` t!Q SC�d(7i'N�
by the following named person(s): (Include corporate name and title if corporate officer)
Full Name Residence
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Signatures
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on � :?O 19�the above named person(s) personally appeared before me and made ;in
oath that the foregoing statement is true.
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CITY CLERK Notary Public
(seal)
Date Commission Expires
Identification Presented
State Tax I.D. # S.S. # 2 /
(if available)
In accordance with the provision of Chapter 337 of the Acts of 1985 and Chapter 110, Section 5, of Mass.
General Laws, business certificates shall be in effect for four (4) years from the date of issue and shall be
renewed each four years thereafter. A statement under oath must be filed with the town clerk upon
discontinuing, retiring, or withdrawing from such business or partnership.
Copies of such certificates shall be available at the address at which such business is conducted and shall be
furnished on request during regular business hours to any person who has purchased goods or services from
such business.
Violations are subiect to a fine of not more than three hundred dollars ($300.00) for each month during which
a.
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�.