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Administrative Use Only FEE: $25.00 (includes 1 certified copy) Number: Type: New Date Filed: Renewal, no change Expiration Date: Renewal, with change In accordance with the provision of Chapter 337 of the Acts of 1985 and Chapter 110, Section 5, of Mass. General Laws, business certificates shall be in effect for four years from the date of issue and shall be renewed each four years thereafter. A statement under oath must be filed with the City Clerk’s office upon discontinuing, retiring, or withdrawing from such business or partnership. Copies of such certificates shall be available at the address at which such business is conducted and shall be furnished on request during regular business hours to any person who has purchased goods or services from such business. Violations are subject to a fine of not more than three hundred dollars ($300.00) for each month during which such violation continues. CITY OF SALEM OFFICE OF THE CITY CLERK BUSINESS CERTIFICATE In conformity with the provisions of Chapter 110, Section 5 of the Massachusetts General Laws, as amended, the undersigned hereby requests the filing of the following business certificate in the City of Salem. Furthermore the undersigned fully understands that the filing of this business certificate does not constitute a license or permit to conduct said business within the City of Salem. ORIGINAL SIGNED CERTIFICATE TO BE FILED AT CITY CLERK’S OFFICE. This Certificate expires four years from the date of issue. If you cease conducting business before that time, the law requires that you withdraw this certificate with the Office of the City Clerk. Name of Business Conducted Business Phone No.: (P.O. Box Not Permitted) Type of Business: Select Business Organization:__ Sole Proprietorship Partnership Limited Liability Corp. (LLC) Corporation By the following named person(s) or corporation: Print Full Name & Title (if partnership, all partners must be included) Corporate or Residential Address & Phone Number Tax I.D. Driver License or State ID State_____ (if available – NOT SOCIAL SECURITY NUMBER) Signatures (to be signed at City Hall or before a Notary Public) (sign here) (sign here) 20___ the above named person(s) personally appeared before me and made an oath that the foregoing statement is true. City Clerk Notary Public Signature & Stamp