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20.085 Cancer ConnectionCity of Northampton Application for Annual License NORTHAMPTON, 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: Cancer Connection Thrift Shop Type of License: Secondhand Dealer Location of Business: 375 South Street Print Name of Applicant: (1i) Cln r% S-�l vx f- 0 u ( A Signature of Applicant: N] oj-x-�_ Address of Applicant: (V) No. cILf> Street z4 Lit(c D rye �s+ ► t A'k In City Council, Referred to Committee on Licenses. ATTEST: City Clerk In City Council, (date) In Committee on Licenses, Voted to recommend that Petition granted, not granted ATTEST: Clerk be Voted that Petition be granted not granted Attest: Clerk to City Council City of Northampton AFFADAVIT OF WAGE COMPLIANCE Name of Business: Cancer Connection Thrift Shoji Location of Business: 375 South Street 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. AFFADAVIT: (V) (Choose 1 below) F—_W This License applicantis nLQt subject to a federal or state criminal or civil judgment, 14 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. Qu��n (Typed or printed name of applicant) (Signature) City of Northampton STATEMENT OF ALL TAXES FILED AND PAID Name of Business: Cancer Connection Thrift Shop Location of Business: 37 uth Street The license (as a/for a) Secondhand Dealer will not be issued unless this certification clause is signed by the applicant listed on the license. I, (V) C1 (I S f n P— a L'�' I n J1 (print name of owner or authorized agent of the business) certify under the penalties of perjury that I, to my best knowledge and belief, have Field all state tax returns and paid all state taxes as required under law. Signature of Owner or Agent (U) or (V) Social Security Number Federal Identification Number GcLnLer ccm% LJ;urn, E rlL 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. Licenses who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law, chapter 62C, section 49A.