21.260 Second Hand Dealer License for Cancer ConnectionCity of Northampton
AFFADAVIT OF WAGE COMPLIANCE
Name of Business: Cancer Connection Thrift Shop
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: 1/) (Choose 1 below)
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.
V) Ck5 if)
Typed or printed name of applicant) Signature)
City 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: (V) r l i S-, (1€- I
Signature of Applicant: (V) 0/(//11:LIA't-&
Address of Applicant: (V) No. c -D Street Zakg-k-TX. Eg4k- M 1
Ito 7
In Committee on Licenses,
In City Council,
Voted to recommend that Petition beReferredtoCommitteeonLicenses.
granted,not granted
ATTEST:
ATTEST:
City Clerk
Clerk
In City Council, date) Voted that Petition be granted
not granted
Attest: Clerk to City Council
City of Northampton
STATEMENT OF ALL TAXES FILED AND PAID
Name of Business: Cancer Connection Thrift Shop
Location of Business: 375 South Street
The license (as a/for a) Secondhand Dealer will not be issued unless this certification clauseissignedbytheapplicantlistedonthelicense.
I, (V) -''` +t C-- 1/44( A (
print name of owner or authoriz ed agent of the
business) certify under the penalties of perjury that I,to my best knowledge and belief,havefieldallstatetaxreturnsandpaidallstatetaxesasrequiredunderlaw.
V)
Signature of Owner or Agent
v)
or (v)
Social Security Number Federal Identification Number
Your social security number will be furnished to the Massachusetts Department of Revenuetodeterminewhetheryouhavemettaxfilingortaxpaymentobligations. 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,section49A.
City of Northampton
Treasurer/Collector's Office
Permit Denial Form
Revised 11-30-2018
REQUESTED BY: Pamela L. Powers, City Clerk
Name of Person, Corporation or Business: Cancer Connection Thrift Shop
Location of Property, Service or Address: 375 South Street,Northampton, MA 01060
All
ermits denied for outstandin amounts must receive confirmation ofgood standinfromtheTreasurer/Collector's Office PRIOR to issuance of the ermit.
For Tax Collector's/Treasurer's Office Use Only
Please list below any tax, assessed to your office that is unpaid for twelve (12) months ormoreafteritsduedate, unless there is a pending abatement or appeal before the AppellateTaxBoard, for the person, corporation, or business entity noted above.
This is a tax exempt entity for FY21 and no amounts are outstanding
Signed: Kris-Erse- 8i4g-e-66
Dated: April 7, 2021
Adopted 5-21 1992 [Ch14 S.14-21 of the 1977 Code]
DeniaURevocation of License City of Northampton