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21.262 Jeffrey Miller Business Owners ApplicationForm 01-Business ``S�Cr�_rirr. City of Northampton Application for Business Owner's Permit - Vehicle for Hire PRINT ALL INFORMATION (except signature) (Check one) New Application Renewal Toda 's Date: D Z (Check one) ©Taxi Service Livery Service Name (First, Middle Last) ,,Q.3� .�` � y' Residential Address 2� 1 C l r�t�.i�,.i ��� �'�, Lez. 5 M4 410 !�-3 Number jlYfYet City/Town State Zip Cade Corportation Name: ' DBA Name: csyvl Business Address 160 g Linr h M0, 0106 Number Street City/Town k State Zip Code Mailing Address Number Street City/Town State Zip Code Telephone Number for the business owner: W i 3 - (, $7 - C6g6 S Telephone Number for the business: N13 - Z30 - 61 Description of Motor Vehicles to be operated under permit: L(2007) Hours of Operation: ---- — --------------.______.�_—_,_______—_—___----- Sworn to this ��0 '�' day of ._ -h-c� , Zp dI , before -— City Clerk i FOR LICENSING AUTHORITY USE In City Council, voted that this petition is Attest: is not granted. Clerk to the City Council rer City Ordinance c. 316 s. 17 Appeal Filed ? hate 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: Cosmic Cab Location of Property, Service or Address: 23 Hooker Avenue, Northampton, MA 01060 All permits denied_ for outstanding amounts must receive confirmation of good standing from the Treasurer/Colleetor's Office PRIOR to issuance of the permit. 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 or more after its due date, unless there is a pending abatement or appeal before the Appellate Tax Board, for the person, corporation, or business entity noted above. No confirmable outstanding obligation 12+ months beyond due date. Signed: X/140se� /— Adopted 5-211992 ICh14 S.14-21 of the 1977 Code] Denial/Revocation of License Dated: 4/28/2021 City of Northampton City of Northampton AFFADAVIT OF WAGE COMPLIANCE Name of Business: Cosmic Location of Business: 23 Hooker Avenue 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: (U] (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. (Typed or pri ted name of applicant) CV) (Signature) City of Northampton STATEMENT OF ALL TAXES FILED AND PAID Name of Business: Cosmic Cab Location of Business: 23 Hooker Avenue The license (as a/for a) Taxi Cab will not be issued unless this certification clause is signed by the applicant listed on the license. 1, (V) `-� -y f v � ` � `� (print name of owner or authorized agent of the kJ 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 (V) or (V) Social Security Number Federal Identification Number 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 Iicense suspension or revocation. This request is made under the authority of Massachusetts General Law, chapter 52C, section 44A.