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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 '-- 0 -- -. �Nti 5; .Qc 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; w*wwww*ww,�**ww*w*ww***w***,�w,�wwwwwwwww*wwwwwww*wwwww*wwwawwwwwwwwwwwwwwww**www*wwwwwwwww*www*wwawwwww Section 2 APPLICANT/ LOCAL MANAGER/ PRINCIPAL OFFICER: f pVS-0,/ 9 ,/TV" � p 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): w*wwwwwwwwµw;wwwwwwwwwaw:wwwwwwwwwwwwwwwww,***wwwwwwww*wwww*w**wwwwwwwwwwwww*wwwwrwwwwww*wwww*w*www** 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, PRINT NAME:SLI AZ7V IE r-w-ok 0 TITLE: CSaote� SIGNATURE- - --- - DATE 1-2e, 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.