Cancer Connection Thrift ShopNORTHAMPTON, MASS.,
PETITION FOR ANNUAL. LICENSE
APR 17 2018
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: 375 South Street
Owner: Signature:
Address: ja Ee,- SY SY • AAA?,'n r MOL 0 l d io0
In City Council:
• This petition was referred to Committee? Yes / No
• In Committee, it was voted that the license be granted? Yes / No / Not Applicable
In City Council:
The City Council voted that the Petition be
Attest:
granted
denied
City Council Clerk
Certification of Status in Good Standing
For State Tax Filing & Payment
Your social security number may be furnished to the Massachusetts Department
of Revenue to determine whether you have met tax filing or tax payment
obligations. Licensees who fail to correct their non -filing or delinquency will be
subject to license suspension or revocation. Your request to furnish this
information is made under the authority of Massachusetts General Law, Chapter
62C, Section 49A.
Business Name: Cancer Connection Thrift Shop
Individual reporting on behalf of the business:
0 �_J &f
I certify under the penalties of perjury that I, to my best knowledge and belief,
have filed all state tax returns and paid all state taxes as required under law.
Signature of Individual:
Social Security Number: (voluntary)
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Signature of Corporate Officer:
Federal Identification Number:
P.T LARGE
WARD
COUNCILORS
William H. Dwight - President
Ryan R- O'DonneA— Vice•Prestdco
CITY COUNCIL
Dennis P-Bidwell
Maureen campy Dennis OF NORT AMPTON
m
James Nash
Gina-Louisc 5ciarra tiIASSACHUSETTS
David A. Murphy
Marianne L. LaBarge
Ahsa F Klein
WAGE COMPLIANCE CERTIFICATES REQUIRED FOR LICENSES 17.235
The Northampton City Council, in determining whether to issue, re -issue, modify, suspend or revoke a
license. under G.L. c. 140,5hall 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
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 printed name of license applicant) Signature
"6--N coa, 06NN't-, C;f -( Z)
(Name of Business)