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Jack Speyer AntiquesNORTHAMPTON, MASS., PETITION FOR ANNUAL LICENSE APR 17 2018 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: Jack Speyer Antiques Type of License: Secondhand Dealer Location: 416 No h M ' St et Owner: Signature: Address: r In City Council: • This petition was referred to Committee? Yes / No • In Committee, it was voted that the license be granted? Yes / No / Not Applicable In City Council: The City Council voted that the Petition be Attest: granted denied City Council Clerk Certification of Status in Good Standing For State Tax Filing & Payment Your social security number may 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 be subject to license suspension or revocation. Your request to furnish this information is made under the authority of Massachusetts General Law, Chapter 62C, Section 49A. Business Name: Jack Speyer Antiques Individual reporting on behalf of the business: I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes as required under law. Signature of Individual: Social Security Number: (voluntary) Signature of Corporate Officer: Federal Identification Number: AT LARGE WARD COUNCILORS William H. Dwight - President Ryan R O'Donnell- Vic. -President Maureen T Carney CITY COUNCIL Dennis P'Bidwell- -CITY OF NORTHAMPTON James Nash Gina -Louise Sciarra 'MASSACHUSETTS David A. Murphy Mlarianne L. LaBarge Alisa F Klem WAGE COMPLIANCE CERTIFICATES REQUIRED FOR LICENSES 17.235 The Northampton City Council, in determining whether to issue, re -issue, modify, suspend or revoke a license. under G.L. t:. 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. Appiicants 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. AFFADAVIT ®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 proAde a wage bond or wage insurance for the period of the Icense. � _'& W a '4- — (Typed or printed name o license applicant) SA tL (Name of Bus' ess