Atlantic Blvd 725 #1 Maza New American Cuisine 2012 CITY OF ATLANTIC BEACH L*l
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233
LOCAL BUSINESS TAX APPLICATION
Section 1
APPLICATION FOR New Business ❑Transfer Ownership ❑Transfer New Location:Previous location
BUSINESS NAME /1/6,41 "qlve e-1'6�y Lam%�f i'i✓�
LOCATION ADDRESS _ �l02� f/"/^-1;c- 3 /V9 S>'e
MAILING ADDRESS /1&40�ei- Or-,lie-
BUSINESS PHONE V0 - Y-63 - 1307 FAX CELL
EMAIL ADDRESS a0 i. eae
NATURE OF THE BUSINESS(Please Be Specific) Se5 hVJRR11rr Lu;4b 2 CQ%'
SQUARE FOOTAGE OF BUSINESS PREMISES a/0
(Include both buildings and outside areas used in conjunction with the business,but not patron parking areas)
NUMBER&TYPE OF VENDING MACHINES(if any) /V
Section 2 �j /
APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER L 4,21/1i✓ P"/V/"
HOME ADDRESS 3-v-V 11-le/L O�C,Ut- :AGK SFc
HOME PHONE .I " /3 d 7 SS#or Fed Employer ID# /USO gal
DATE OF BIRTH g( ,`. DRIVER'S LICENSE# H (0 3S-///'- (a9 - (Attach copy)
STATE LICENSE/CERTIFICATION/REGISTRATION#(if applicable,attach copy)
Section 3
I,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
compliant with all provisions of the C e of Ordinances pertaining to conducting a business in the City of Atlantic Beach.
Signature Title
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/BuildingFe Paid n 0 '' Business Tax Receipt#
❑FULL YR ❑HALF YR Business Tax Amount $ Code#&Classification
I�
❑ Fictitious Name Reg. ❑ Corporation Reg. ❑ State Reg/Cert/Lic# El Health Cert#
OTHER Requires Co ission Appr val Yes N'6-'ApprovedJdenied by Commission on
ZONING APPROVED BY DATE 0�02�201
BUILDING DEPT APPROVED BY jk4f& DATE Ad - Z-4 -1 9,-
FIRE
FIRE DEPT APPROVED BY DATE
CITY CLERK APPROVED BY DATE
Last Business Use: �6tww( Last Business Name: FVD-0 WeK
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