CITY OF MELROSE Kristin Foote City Clerk OFFICE 562 Main Street Melrose, Massachusetts 02176 (781) 979-4115 Business Certificate #_____________________ Expiration Date ___________ Business Certificate Application Step 1. Treasurer/Collector’s Office Requirements:  Obtain proof of good standing from the Treasurer/Collector’s Office Step 2. Inspectional Services Department Requirements:  Complete attached Inspectional Services Occupancy Permit Application  Submit application and fee directly to Inspectional Services Step 3. City Clerk’s Office Requirements:  Provide Occupancy Permit with completed Business Certificate Application  Include property owner’s authorization on page 2, if applicable  $60 Filing Fee; valid for 4 years BUSINESS CONTACT INFORMATION Business Name Applicant’s Name Business Address Social Security Number or Federal Identification Number New Business:  Renewal:  Mailing Address Telephone Number of Owner Email Address 24 hour Emergency Contact Name: Phone: I/We understand that Filing a Business Certificate is NOT a license from the City Clerk, City of Melrose, or any of its agents or employees to operate a business. I/We understand that the filing of this Business Certificate DOES NOT necessarily mean that the business complies with the Zoning Laws of the City. I swear or affirm that the statements contained in this certificate are true. Additionally, I /We certify under the penalties of perjury that I /We, to the best of my knowledge and belief, have filed all state tax returns and paid all state taxes as required under law. Additionally, I/We certify that I/We have personally answered all the questions on this application and that they are accurate and true to the best of my knowledge. This Certificate will not be issued unless this certification clause is signed by the applicant. Your social security number will be furnished to the MASS DOR to determine whether you have met tax filing or tax payment obligations. Applicants who fail to correct their non-filing or delinquency will be subject to certificate suspension or revocation. This request is made under the authority of MGL, Chapter 62C, Section 49A. Applicant’s Signature:___________________________________________________Date:_______________________ On this ______day of______________, 20__, before me, the undersigned personally appeared _______________________________, proved to me, through satisfactory evidence of identification, which was/were __________________________________, to be the person(s) whose name is signed above, and swore or affirmed to me that the contents of the document are truthful and accurate to the best of his/her knowledge and belief. _____________________________________________________________ Clerk/forms/business certificate application. Updated October 2021 1 CITY OF MELROSE OFFICE 562 Main Street Melrose, Massachusetts 02176 (781) 979-4115 Notary Public, City Clerk, Assistant City Clerk, Senior Clerk Kristin Foote City Clerk Business Certificate Application (continued) DESCRIPTION OF BUSINESS ACTIVITIES TO BE DONE AT THE ABOVE ADDRESS Is this a home based business? YES NO Will there be any exterior changes to this property, including signs? YES NO Will there be any noise, emissions, etc. noticeable to persons adjacent to this property? YES NO Is this business solely a telephone or marketing business? YES NO Will customers visit the property? YES NO Brief description of the business: List all major equipment used in this business: Where on the premises will business be conducted? If yes, how many people are expected at one time? List materials sold or stored at the property: PROPERTY OWNER AUTHORIZATION (to be completed only if the applicant is not the legal property owner) I, __________________________________________, own the property at ______________________________________, and authorize _____________________________________________________(applicant) to operate his/her business from this address. _____________________________________________________________________ Property Owner Signature TREASURER/COLLECTOR ____________________________ Date INSPECTIONAL SERVICES Approved – account(s) current Denied Pending Approved – with C/O attached Denied Pending Comments: Comments: ________________________________________________ Treasurer/Collector’s Signature Date __________________________________________________ Building Inspector’s Signature Date C