20.150 Second Hand Dealer License Application for Retro GenieNORTHAMPTON, 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:
Owner:
Type of License: _Secondhand Dealer'
Location:
s
(Sign Here
No. Street i C S�_
In City Council,
Referred to Committee on Licenses.
ATTEST:
City Clerk
In-city-Counci
In Committee on Licenses,
Voted to recommend that Petition be
granted
ATTEST:
Clerk
granted.
Attest: Clerk to City Council
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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. c. 140,shall require that a potential or current licensee certify that they are not
subject to d 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 tabor 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 debar Wren( for violation of
the above laws, either voluntarily or involuntarily, or that have been prohibited from contracting with
the CommonWPalth or any of its agenc Ps or subdivii.om shall be prohibited from holding, or rontinuing
to hold, licenses issued under G L. c. 140, for the entire period of debarment or other stated time
period.
applC.ants m,itir 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.
AFFADAVI T
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
GA- C. 1�19, c. 151, or the Fair Labor Standards Act within the list three years.
❑This License applicant is subject to a federal or state criminal or civil judgment, administratwe
citaVcn, 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.
;Typed or printed name of license a pli ant)
--- - " 'v—�&b
i•Narrie of Business)
I certify under the penalries of perjury that I, to my best
knowledge and belief, have filed all state tax 'returns any' paid
all state taxes as required under law.
n&V
VSignature oftndividual By: Corporate Officer
�oci�"erzu"rity#_Funtary
or Federal lden'Lification 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 obtigations. Licensees who fail to correct their non -filing or
delinquency will be subiect to license susl2ension or revocation. Tuffs
request is made under the authority of Massachusetts General Law,
Chanter 62C, Section 49A.