48 W 6th St.OL APP CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233
LOCAL BUSINESS TAX APPLICATION
Section 1
APPLICATION TYPE: NIewBusinessTransfer of Ownership 3Yd .4VS7. 50u114
4 Transfer to New Location: Previous Location T6FL- A-2,1-5-0
BUSINESS NAME: CoAmp I a,,,k Ass 6.C.: GLG di.b, rl�y Va(I. E bi ur s
LOCATION ADDRESS: ItrN E51" G�i STi2rc"1T . R , rt-. 71. 33
MAILING ADDRESS: I3lq 2" STWAaffr A/Qkl14 � R. 3zz50
BUSINESS PHONE: qoY— 4fl7-1o1S FAX: f✓i4 CELL: S,4.HE
EMAIL ADDRESS: �a r
BUSINESS ENTITY IDENTIFICATION NUMBER: Federal Employer I.D.Number
... �L.�.
or
Social Security Number
PLEASE EXPLAIN THE NATURE OF THE BUSINESS:
Ss7_�E s� �2E�i�ri2 O F 6-2,0mf t c c �,►kes Nov-
SQUARE FOOTAGE OF BUSINESS PREMISES:
(Include both buildings and outside areas used in conjunction with the business but not patron parking areas.)
Will the following be served? Food: Yes S
Alcohol: Yes C5) If yes,Select One: 1 COP 2COP 4COP
If restaurant,will dogs be allowed? Yes No
Will you have any vending machines? Yes 0 If yes, please provide quantity and type below:
Section 2 APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER:_ G✓/LL1,4 i'�
W.
HOME ADDRESS: /3/q 2d SVZe r /✓DR.W Ij, �B SO
HOME PHONE: QbY- q 97- zo i S CELL: 51*uE
DATE OF BIRTH: $'3—x3 DRIVERS LICENSE#: C Sb 0- 930 - 53- oZ 93-0 (Please attach a copy.)
EMAIL ADDRESS: Coyvro4 W' cJN—est �A.n'�
STATE LICENSE/CERTIFICATION/REGISTRATION#(if applicable,
Section 3 ( U `� `J
I, the undersigned,swear that the above statements are true and corr
any change in the above information.
I further understand that issuance of a Local Business Tax Receipt
responsibility of compliance with all provisions of the Code of Ordin:
City of Atlantic Beach. ,� _,� `• ���
PRINT NAME: W I&,4-ij4M .T CaN'eo Y JyZ• TI '�►
SIGNATURE Df
1� to
No person, firm or corporation shall en ge in or manage any trade, busii
without first obtaining a Local Business Tax Receipt. Application and/or pa
a receipt.