535 (363 #5 ) ATLANTIC BLVD - TAX APPLICATION . 5\\\)\V S Ov-iihke p4",_-44_, 4v. 7,erx,frti 9/2q/ Qo Y-6
C01a41 CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233
LOCAL BUSINESS TAX APPLICATION
....5_ 35
Section 1 �� ���
APPLICATION FOR ❑ New Business ❑Transfer Ownership Transfer New Location:Previous location_
BUSINESS NAME c5h at)CO-Se-, /3 Shc-M . p J4/wing 5 G'vGLGS S orl"Jz-4
LOCATION ADDRESS 3C3 .5�d irn riC/ ,`g/U �'
MAILING ADDRESS f l�? �tr P,9,5 Cc Al,/` 1Z.- 32-o ErL
BUSINESS PHONE
FAX CELL yo y 6'3/-6 7o O or 608(0 7 7`1
EMAIL ADDRESS G L r C(Z S.S O Y�,S h o W ne.�i e, ® C�C��`" - "'Q� -
NATURE OF TIE BUSINESS(Please Be Specific) L Jt S CliC..-C-ti S_ra r'. ---
SQUARE FOOTAGE OF BUSINESS PREMISES ?Si, sk
(Include both buildings and outside areas used in conjunction with the btl5iness,but not patron parking areas)
NUMBER&TYPE OF VENDING MACHINES(if any)
x:k+i.*tEx:t***Prix`:ko#,k:k**ic***************k*********F****#.#:#>h************************ :i,::;ex:<*:(:** **i:*< *e:g.k* *
Section 2
APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER 1*c b W d// ---
HOMEADDRESS i/ frf 427- A/97- . C&. -
HOME PHONE g7 3 -l a V/ SS#or Fed Employer ID# d 6 0 -7 78` z.--________.
DATE OF BIRTH. .72,`-/At. DRIVER'S LICENSE# (Mach 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 in the
above information.
I further understand tha ' uance of a Local Business Tax Receipt by the City Clerk in no way relieves me of the responsibility of
compliance with al : ovision of re Code o rdinances pertaining to conducting a burin the City of Atlantic Beach.
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Si natun!"..— Title
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PRINT NAME Date
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No person,firm or corporation: AA / ,
thout h
first obtaining a Local Business _�f� ? / **
Section 4(For Office Use Onl} v
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CI FULL YR El HALF YR 535 Ali 6I✓1
N a, ' sia ..eoce❑ Fictitious Name Reg. ❑ CI / ( 4 ,,04)-< O)/
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OTHER Rec I ' /• lv
ZONING APPROVED BY— ' 61)64.° / n , r ��
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BUILDING DEPT APPROVED ,tww
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FIRE DEPT APPROVED BY__ /- 6 T-1 0/66
CITY CLERK APPROVED BY • #3 - e 40 ( .4 �
Last Business Use: Last Business Name:
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