32A-255 (159) CITY OF NORTHAMPTON
INNHOLDER LICENSE RENEWAL AFFIDAVIT
NAME OF MANAGER 0.e- rr, ,144,
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BUSINESS NAME Do✓1„-r w A..M n T-UJ J40' -e
ADDRESS OF PREMISES K r1 c,
ADDRESS OF BUSINESS IF DIFFERENT
TELEPHONE NUMBER OF MANAGER
DESCRIPTION OF PREMISES
(number of rooms, number of floors, common area 6)
I am applying for a renewal of the above license and give
oath that the premises have not been altered or expanded without
the Commission' s knowledge and assent.
Pursuant to M. G. L. Ch. 62C, Sec. 49A, I certify under the
penalties of perjury that I/It, to the best of my knowledge and
belief, have filed all state tax returns and paid all state taxes
required under law.
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S. S. # or F. I. D. of Signature 'of Owner/"Officer
Corporation