Feeding Tube RecordsNORTHAMPTON, MASS.,
To the Honorable City Council of the City of Northampton:
The undersigned respectfully petitions your honorable body for a License as follows:
Name of Business:
Type of License:
Feeding Tube Records
Secondhand Dealer
Location: 221 Pine Street, Room 141 .0. Bo 7)
(Sign Here)
No. Street
In City Council,
Referred to Committee on Licenses.
ATTEST:
City Clerk
In City Council,
In Committee on Licenses,
Voted to recommend that Petition be
granted
ATTEST:
Clerk
Voted that Petition be _ granted.
Attest: City Clerk
I certify under the penalties of perjury that I, to my best
knowledge and belief, have filed. all. state tax returns and paid
;aHate taxes as require r law.
* Signature of indivi al By: Corporate Officer
** Social Security # Voluntary
or Federal Identification Number
* This license will not be issued unless this certification clause is signed
by the applicant.
** Your social security number will be furnished to the Massachusetts
Department of Revenue to determine whether you have met tax filing or
tax payment obligations. Licensees who fail to correct their non -filing or
delinquency will_bc_subject to license suspension or revocation. This
request is made under the authority of Massachusetts General Law,
Chapter 62C, Section 49A.
AT LAR{3f
WAkD
C 0UNC1101ZS
Wilham li. Dwight . President
Kyan K O'Donnell— Vicc•I' escd• t
Maurcrn T trantcv
Dennis ?""Bidwell
_i James Nash
d Gina -Lows:-, &iarra
4 David A. Nlusphy
( Marianne L. LzBarg, c
Alisa F YActn
CITY COUI CIL
'CITY OF INOR 1-f L,\- MPTON
NIASSACHT.. SETTS
WAGE COMPLIANCE CERTIFICATES REQUIRED 1�011 LICENSES 17.235
The Northampton City Council, in determining whether to issue, re -issue, modify, suspend or revoke a
license. under G.L. C. 140,shall require that a potential or current licensee certify that they are not
subject to a federal or state criminal or civil judgment, administrative citation, order or final
administrative determination resulting from a violation of G.L. c. 149, c. 151, or the Fair Labor Standards
,act. The City Council may require a wage bond or insurance be posted by any potential licensee who
does not certify that they are not subject to a federal or state criminal or civil judgment, administrative
citation, order or final administrative determination resulting from a violation of G.L. c 149, c. 151, or
the Fair Labor Standards Act. Licensees that are subject to a state or federal debarment for violation of
the above laws, either voluntarily or involuntarily, or that have been prohibited from contracting with
the Commonwealth or any of its agencies or subdivisions shall be prohibited from holding, or continuing
to hold, licenses issued under G.L. c. 140, for the entire period of debarment or other stated time
period.
Applicants must check box 1 or box 2 as applicable and must sign this Form, certifying compliance
with the requirements set out in this Form. This Form must be included with the application.
AFFADAV
This License applicant is not subject to a federal or state criminal or civil judgment,
administrative citation, order or final administrative determination resulting from a violation of
G.L. c. 149, c. 151, or the Fair Labor Standards Act within the last three years.
❑ This License applicant is subject to a federal or state criminal or civil judgment, administrative
citation, order or final administrative determination resulting from a violation of G.L. c. 149, c.
151, or the Fair Labor Standards Act within the last three years. This applicant will provide a
wage bond or wage insurance for the period of the license.
Lee
( Typed or printed name of license applicant) Signature
// _•._ram 3 QeCo 2 5
(!Name of Business)