983 ATLANTIC BLVD #123 OL APP CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233
LOCAL BUSINESS TAX APPLICATION
Section 1 /
APPLICATION FOR H ew Business ❑Transfer Ownership ❑Transfer New Location:Previous location
BUSINESS NAME ��A LAN sw u n
LOCATION ADDRESS 98S q t fl1V TZC -'---
MAILING ADDRESS 616 (1AA&-MIA
? -T N�-�T► n1 L
BUSINESS PHONE Re 2"C S9-MIA _ FAX CELL
EMAIL ADDRESS IYVA�
NATURE OF THE BUSINESS(Please Be Specific) 11C01 O CPtI ON
SQUARE FOOTAGE OF BUSINESS PREMISES 00 S(�
(Include both buildings and outside areas used in conjunction with the business,but not patron parking areas)
NUMBER&TYPE OF VENDING MACHINES(if any)
x#*+k+k�xkk#Kk�;B:k-k�f•#�x#k�k�k�:kf::k�=kkk#kk*�xkk�+k#xk�kk*&*+k##kM��k�e�C+k+i::k���"*�::x*:k�xkc+k�8<�k#x+k*�F:k�kk-k$k*kki*�k�xk*>Fk>:<*
Section 2 ► -rnlr
APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER "i\cA -�-
HOME ADDRESSMAQQ�. �' STNTl 1 r�( _
HOME PHONE &, - 65`lX1_/ SS#or Fed Employer ID#
DATE OF BIRTH 01 -Or;.- $R DRIVER'S LICENSE# s c� I q - ()I X -A 7-:5W" (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 int e
above information.
I further understand that issuance of a Local Business Tax Receipt by the City Cleric 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.
Signature
rtle'
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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.
Zonin uildin Fee Paid on Business Tax Receipt#
Section 4(For Office Use Only) �r�W�� ! g
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❑FULL YR ❑HALF YR Business Tax Amount Code#&Classification
El Fictitious Name Reg. ❑ Corporation Reg. El Corporation Reg/Cert/Lic#
❑Health Cert#
OTHER Requires Commission Approval Yes No Approved/denied by Commission on
DATE
ZONING APPROVED BY
BUILDING DEPT APPROVED BY '^' •AC,�Tc�►( DATE 6 4
FIRE DEPT APPROVED BY taDATE 6
DATE
CITY CLERK APPROVED BY
Last Business Use: *4&-,e' �!tLtie—e
Last Business Name: ��