Business Certificate Worksheet Form Page 3
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1
2
3BUSINESS CERTIFICATE
C I T Y
O F
S P R I N G F I E L D
Commonwealth of Massachusetts
IN CONFORMITY WITH THE PROVISIONS OF CHAPTER 110, SECTION 5 OF THE GENERAL LAW, AS
AMENDED, THE UNDERSIGNED HEREBY DECLARE THAT A BUSINESS IS CONDUCTED UNDER THE
TITLE OF:
___________________________________________________________________________
AT
______________________________________________________________________________
(
ADDRESS)
IS THE ABOVE ADDRESS THE PROPER MAILING ADDRESS FOR ALL PUBLIC CORRESPONDANCE: YES
_____ NO ______. IF NOT, PLEASE PROVIDE MAILING ADDRESS BELOW.
SOCIAL SECURITY # _______/______/_________ OR FEDERAL EIN# _______/_______________________
BUSINESS TELEPHONE NUMBER ______/__________________ HOME # ______/____________________
TYPE OF BUSINESS: _________________________________________________
NUMBER OF EMPLOYEES: _______ (PROOF OF STATE WORKER’S COMPENSATION INSURANCE IS
REQUIRED IF YOU HAVE EMPLOYEES, THE CITY WILL NOT ACCEPT AN APPLIACTION WITHOUT
PROOF OF WORKER’S COMPENSATION INSURANCE)
BY THE FOLLOWING NAMED PERSON(S):
FULL NAME
RESIDENCE
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
SIGNATURE(S):
_______________________________________________
_________________________________________
_______________________________________________
_________________________________________
ON _________________________________________ THE ABOVE NAMED PERSON(S) PERSONALLY APPEARED
BEFORE ME AND MADE OATH THAT THE FOREGOING STATEMENT IS TRUE.
Signature: ___________________________________________________________
Print Name: _________________________________________________________
NOTARY PUBLIC; MY COMMSIION EXPIRES________________
IN ACCORDANCE WITH THE PROVISIONS OF CHAPTER 110, SECTION 5 OF MASSACHUSETTS GENERAL LAW,
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 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 UPON 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.
THE FILING OF A BUSINESS CERTIFICATE DOES NOT IMPLY ZONING ORDINANCE COMPLIANCE AND IT IS NOT A
LICENSE OR PERMIT TO CONDUCT A BUSINESS IN THE CITY OF SPRINGFIELD.
THIS CERTIFICATE VOID AFTER __________________________________________
2/07
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