363 Atl. Blvd, #9, KITCHEN ENVY BTR CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233
LOCAL BUSINESS TAX APPLICATION
Section 1
APPLICATION TYPE: New Business Transfer of Ownership
Transfer to New Location:Previous Location
BUSINESS NAME: VxNkE(V� _V I(-V--
LOCATION ADDRESS: :'663
MAILING ADDRESS: -NMEM V��-tke `S.c�
BUSINESS PHONE: �C 651�ad U FAX: CELL: (kriL ,
EMAIL ADDRESS: MkGr\Ce- )t\\Nt Y1- le:'\Vy`• M(X�
BUSINESS ENTITY IDENTIFICATION NUMBER: Federal Employer I.D.Number 'G�) L4 O p O'er
or
Social Security Number
PLEASE EXPLAIN THE NATURE OF THE BUSINESS:
SQUARE FOOTAGE OF BUSINESS PREMISES: g�o� —
(Include both buildings and outside areas used in conjunction with the business,but not patron parking areas.)
Will the following be served? Food: Yes No
J Alcohol: Yes No If yes, Select One: 1 COP 2COP 4COP
If restaurant,will dogs be allowed? Yes No
Will you have any vending machines? Yes No If yes, please provide quantity and type below:
Section 2
APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER:
HOME ADDRESS: aa'a:5 d� � 1 kVt -t---
HOME PHONE:Ookw3yMS CELL: 1
gam
DATE OF BIRTH:O1•tJ 1'1-- DRIVERS LICENSE#: (Please attach a copy.)
EMAIL ADDRESS: Myoykc— ec\yu• Mn
STATE LICENSE/CERTIFICATION/REGISTRATION#(if applicable,attach copy): tJ Qe
Section 3
I,the undersigned,swear that the above statements are true and core v — ��� is
any change in the above information.
I further understand that issuance of a Local Business Tax Receipi �`�v ( r e
responsibility of compliance with all provisions of the Code of Ordh 111 e
City of Atlantic Beach.
PRINT NAME - I
SIGNATURE '�C�� Q I
No person, firm or corporation shall engage in or manage any trade, bu!
without fust obtaining a Local Business Tax Receipt.Application and/or I
a receipt.