299 ATLANTIC BLVD #1 - LOCAL BUS TAX APPLICATION CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233
LOCAL BUSINESS TAX APPLICATION
Section 1
APPLICATION FOR ❑ New Business XTransfer Ownership OTransferNew Location:Previous location
BUSINESS NAME ie/°-M A X /16/4 TH r O a D S L.C.-C..
LOCATION ADDRESS 2 9 9 -/ /97-4,7,14,7/c. .13 v D , 7-LA iv Ti C tic l-1 f C 3 Z Z 3
MAILING ADDRESS 4 s 57-1-1 /9 v N APT 5, 7 ) x /3 eltcr1 r` 3 2 2 s a
BUSINESS PHONE 90 N- 73'1 /0 29 ` FAX CELL
EMAIL ADDRESS /3/o y►'1 fl X H-51=I LTH /-o a,v 5 Y/3/d C) S•
�Pc-��CAWS
NATURE OF THE BUSINESS(Please Be Specific) /2 E TA It- HaA LTN F000) v
SQUARE FOOTAGE OF BUSINESS PREMISES 22 00 D ------
(Include both buildings and outside areas used in conjunction with the business,but not patron parking areas)
NUMBER&TYPE OF VENDING MACHINES(if any) No iL --
Section 2 ✓3�i/in/ w �� T7L�
APPLICANT/LOCAL MANAGER!PRINCIPAL OFFICER
HOME ADDRESS `/4'S` S777‘ /4_-' /N A-P7: r- , 5i X b14
HOME PHONE �'o'f-2 3 9--/O2 c) SS#or Fed Employer ID#_ ----
DATE OF BIRTH 1'2-6 DRIVER'S LICENSE# 1>30.2 O 6.D 6-1, 0 01 O (Attach copy)
STATE LICENSE/CERTIFICATION/REGISTRA.TION#(if applicable,attach copy)
Section 3
1,the undersigned,swear that the above statements are true and correct and I agree to notify the City Clerk if there is any change in the
above information.
I further understand that issuance of a Local Business Tax Receipt by the City Clerk 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.
1�
Signature Title
vtJ DacT/z &e. //9//S' _.
PRINT NAME Date
No person,firm or corporation shall engage in or manage any trade,business,profession,or 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.
Section 4(For Office Use Only) $100.00-Zoning/Building Fee Paid on Business Tax Receipt#_�_
❑FULL YR ❑HALF YR Business Tax Amount $ Code#&Classification
•
❑ Fictitious Name Reg. ❑ Corporation Reg. ❑ State Reg/Cert/Lic#
❑Health Cert#
OTHER Requires Commission Approval Yes No Approved/denied by Commission ou
ZONING APPROVED BY DATE
BUILDING DEPT APPROVED BY h2+—� �'k DATE 4 1 0 3 '
FIRE DEPT APPROVED BY DATE
CITY CLERK APPROVED BY DATE
Last Business Use: Last Business Name: S A.