DOLLAR TREE OL CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD, ATLANTIC BEACH, FL 32233
LOCAL BUSINESS TAX APPLICATION
Section I
APPLICATION TYPE: ®New Business ❑Transfer of Ownership
Transfer to New Location: Previous Location
BUSINESS NAME: -t)C)Ao ' 7 Ce e- 1�7
L
LOCATION ADDRESS: a�o� Q,,g \ Wl I� UI�a(�l
MAILING ADDRESS:5 i AVO P �-k�S,4--n S ti k v�" °�33'�
BUSINESS PHONEMOCI- aLI 1 ,D (11) FAX: 3d,\-5,.1 CELL:
EMAIL ADDRESS: a-S.yy\n -- a C. -m p
BUSINESS ENTITY IDENTIFICATION NUMBER: Federal Employer I.D.Number 5c/- 0�c�
or
Social Security Number
PLEASE EXPLAIN THE NATURE OF THE BUSINESS:
n h ► e�1 (��(�,�,� �CIT
SQUARE FOOTAGE FOOTAGE OF BUSINESS PREMISES: , qT3
(include both buildings and outside areas used in conjunction with the business, but not patron parking areas.)
Will Ohe following be served? Food: YesgNo
Alcohol: YesIf yes, Select One: ICOP 2COP 4COP
If restaurant,will dogs be allowed? Yes
Will you have any vending machines? Yes No If yes, please provide quantity and type below:
Section 2
APPLICANT/ LOCAL MANAGER/PRINCIPAL OFFI ER: r nee- sytre-�
HOME ADDRESS: I- Cl �fi41C�
HOME PHONE: _ CELL: _
DATE OF BIRTH: ff5 DRIVERS LICENSE#: U-4 ease attach a copy.)
EMAIL ADDRESS:
STATE LICENSE/CERTIFICATION/REGISTRATION #(if applicable, attach copy):
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Sectipn 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 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. Deborah E.Miller
1� // Vice President and Assistant
PRINT NAME: bel2ffG'& �r f t► !l e- TITLE: General Counsel/Real Estate
SIG ATURE l� X - A� Y /X JC DATE 5—& /S
No prson, firm or corporation shall engage in or manage any trade, business, profession, or occupation in Atlantic Beach
with tit first obtaining a Local Business Tax Receipt. Application and/or payment does not constitute approval or issuance of
a rec ipt.
I