Date Recorded ______________

TOWN OF TISBURY

CHANGE OF BUSINESS CERTIFICATE

IN CONFORMITY WITH THE PROVISIONS OF CHAPTER 110, SECTION 5 OF THE MASSACHUSETTS GENERAL LAWS, AS AMENDED, THE UNDERSIGNED HEREBY DECLARE THAT I (WE) HAVE THIS DAY

NAME OF BUSINESS  
CONDUCTED AT   TELEPHONE  
MAILING ADDRESS  

SOLD OR DISCONTINUED

DATE DISCONTINUED OR SOLD  
BUSINESS WAS SOLD TO

(NEW OWNER'S NAME AND MAILING ADDRESS)

  
INVENTORY WAS SOLD TO

(NEW OWNER'S NAME AND MAILING ADDRESS)

  
IF FILING AS EXECUTOR OR ADMINISTRATOR OF AN ESTATE, PLEASE FILL IN NAME OF

DECEASED ________________________________________ AND DATE OF DEATH ________________________.

WITHDRAWAL - RESIDENCE CHANGE - OTHER

WITHDRAWAL

 PERSON WITHDRAWING  
  DATE OF WITHDRAWAL  

RESIDENCE CHANGE

 NEW RESIDENCE  
  OTHER NEW INFO  
 

Signed under the penalties of perjury:

_________________________________________________
Owner(s)/corporate officer signature

IN ACCORDANCE WITH THE PROVISIONS OF CHAPTER 110, SECTION 5 OF THE MASS. GENERAL LAWS, BUSINESS CERTIFICATES SHALL BE IN EFFECT FOR FOUR YEARS FROM THE DATE OF ISSUE AND SHALL BE RENEWED EVERY FOUR YEARS THEREAFTER. A STATEMENT UNDER OATH MUST BE FILED WITH THE TOWN 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 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) FOR EACH MONTH DURING WHICH SUCH VIOLATION CONTINUES.

FOR OFFICE OR NOTARY USE ONLY

Date: _________________

Then personally appeared before me the above named

___________________________________________

and made oath that the foregoing is true.

__________________________________________

Town Clerk/Notary

My commission expires: ___________________________

TISBURY TOWN CLERK PO Box 606, Vineyard Haven, MA 02568-0606 Phone: 508-696-4215 Fax: 508-693-5876