7-6-23 COAB Exh. 1Section 1
APPLICATION TYPE;
BUSINESS NAME: _
LOCATION ADDRESS:
MAILING ADDRESS:
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD, ATLANTIC BEACH, FL 32233
LOCAL BUSINESS TAXAPPLICAIM
New Business 11 Transfer of Ownership
Transfer to New Location: Previous Location
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BUSINESS PHONE: lJyb��._ y?3 FAX:
EMAIL ADDTtpce•
BUSINESS ENTITY IDENTIFICATION NUMBER:
&d --i2 2 �33
CELL:
Federal Employer I,D, Number e/6 /("13
a `PCS
or
PLEASE EXPLAIN THE NATURE OF THE BUSINESS: Social Security NumbercQ S?- s 6 - d- I/q/
ul SCE k/ec�.'CS E�et,:e�
SQUARE FOOTAGE OF BUSINESS PREMISES: /123
(Include I;oth buildings and outside areas used in conjunction with the business, but not patron parking areas.)
Will the following be served? Food; Yes ao
Icoh 1' Yes ❑✓'No If yes, Select One:
If �2COP ❑4COP
If restaurant, will dogs be allowed? 17Yes ❑ No
Will you have any vending machines? Yes ENO Ifes lease
Y � p provide quantity and type below;
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Section 2
APPLICANT/ LOCAL MANAGER/ PRINCIPAL OFFICER: f pVS-0,/ 9 ,/TV"
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HOMEADDRESS:
X20
HOME PHONE: CELL: 90y -647-7V2_?
DATE OF BIRTH: 3"z I _S- 7 _ DRIVBRs LTCR1,rsE; -
(Please attach a copy,)
EMAIL ADDRESS: 00�-t�
STATE LICENSE/CERTIFICATION/REGISTRATION # (If applicable, attach copy):
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Section 3
I, the undersigned, swear that the above statements are true and correct and I agree to notify the City if there is any
change in the above information,
I further understand that issuance of a Local Business Tax Receipt by the City in no way relieves me of the
responsibility of compliance with all provisions of the Code of Ordinances pertaining to conducting a business in the
City of Atlantic Beach,
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SIGNATURE- -
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Nu person, firm or corporation shall engage in or manage any trade, business, profession, of occupation in Atlantic Beach
without first obtaining a Local Business Tax Receipt, Application and/or payment does not constitute approval or issuance of
a receipt.