1500 MAYPORT RD OL APP r►� � I
CITY OF ATLANTIC BEACH \� �
800 SEMINOLE ROAD,ATLANTIC BEACH, FL 32233
LOCAL BUSINESS TAX APPLICATION
Section I
APPLICATION TYPE: New Business ldfNj Transfer of Ownership
Transfer to New Location: Previous Location
BUSINESS NAME: % r "
LOCATION ADDRESS:_ bxm U4�DC-� (�1L--, JClC nv�I l�e
MAILING ADDRESS: 0
BUSINESS PHONE: - , ` FAX: CELL:
EMAIL ADDRESS: ���o t�i I l��I�,��Y IaSV C140
BUSINESS ENTITY IDENTIFICATION NUMBER: Federal Employer I.D.Number 4 063
or
Social Securit3
PLEASE EXPLAIN THE NATURE OF THE BUSINESS:
ir�4 us v Y—,
SQUARE FOOTAGE OF BUSINESS PREMISES: 3' J C1 Q 6 �0
(Include both buildings and outside areas usedin conjunction with the bu,
Will the following be served? od: Yes %
FoNo
Alcohol: YesNo if yes,Seb
If restaurant,will dogs be allowed? Yes o h4r--L-1>
Will you have any vending machines? Yes NoIt
Section 2
APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER:
HOME ADDRESS:
HOME PHONE: CELL: 96J -.233 - ,-Y-Z60
DATE OF BIRTH: DRIVERS LICENSE#: /(Z y�9' 77-1VZ-� (Please attach a copy.)
EMAIL ADDRESS: iti r K/� nJ0 -I- (am
STATE LICENSE/CERTIFICATION/REGISTRATION#(if applicable,attach copy): SEA v9Wl�9gb0
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.
PRINT NAME: TITLE: C r�
SIGNATURE 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.