21.270 Feeding Tube RecordsCity of Northampton
AFFADAVIT OF WAGE COMPLIANCE
Name of Business: Fe-eding Tube Records
Location of Business: 90 King StreCt(P.O. Box 2
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)
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 h-` --- —I _ ..
wage bond or wage insurance for the period of t
(Typed or printed name of applicant)
City of Northampton
STATEMENT OF ALL TAXES FILED AND PAID
Name of Business:
Location of Business:
Feeding Tube Records
Kin r (P.O. Box 627)
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.
1, (V) L" -" (print name of owner or authorized agent of the
business) certify under the penalties of perjury that 1, 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
i (i� (V) I - - 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 license suspension or revocation.
This request is made under the authority of Massachusetts General Law, chapter 62c, section
49A.