983 ATLANTIC BLVD #121 - LOCAL BUS TAX APPLICATION CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233
LOCAL BUSINESS TAX APPLICATION
Section 1
APPLICATION FOR 0 New Business ❑Transfer Ownership OTransfer New Location:Previous location
BUSINESS NAME D. f " S.i /u-,)/ 0 /� /�/
LOCATION ADDRESS ��.3 4-4-14,--1 `�, ✓/� �
MAILING ADDRESS /0 33 / ' 6 • J fo-� v.%/ �/ Y2 2/�-
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BUSINESS PHONE yoY 0OF--7 0 FAX CELL /CO >` -b OF-0J-7 n
EMAIL ADDRESS D472 -/144'')G✓4.eze"e.) ! Le SO t4.--.P6 ``jf .
NATURE OF THE BUSINESS(Please Be Specific) /12.1 f1 (-0/•'f i/ S/9A)h1
f E - If r - . IL'fqo
SQUARE FOOTAGE OF BUSINESS PREMISES /O
(Include both buildings and outside areas used in conjunction with the business,but not patron parking areas)
NUMBER&TYPE OF VENDING MACHINES(if any) N c/7 t-
Section 2 L %ice+v" 'I /��4 4 //� /2�'`V
APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER
HOME ADDRESS O 3 �i�-//a/ e°,r 4. l 1 E 7s J° i A rl -7l Z/d
HOME PHONE q D p D ( 0 .1--- 7 ° SS#or Fed Employer ID# ,-,2L 7 - 07 3'2 6
DATE OF BIRTH � -f/- /1`-1"3 DRIVER'S LICENSE#44,54,S--,i.,2-St - 53 -e5/-d' (Attach copy)
STATE LICENSE/CERTIFICATION/REGISTRATION#(if applicable,attach copy)
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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 that issuance of a Local Business Tax Receipt by the City Clerk in no way relieves me of the responsibility of
corn i. e with all provisions of the Code of Ordinances pertaining to conducting a business in the City of Atlantic Beach.
(e Signature Title
/ ^ / r
L a). e /2- M2/V&lQ 2,ieL�� -! - /S
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.
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Section 4(For Office Use Only) $100.00-Zoning/Building Fee Paid on Business Tax Receipt#
❑FULL YR ❑HALF YR Business Tax Amount $ Code#&Classification
•
❑ Fictitious Name Reg. ❑ Corporation Reg. 0 State Reg/CertlLic#
❑Health Cert#
OTHER Requires Commission Approval Yes No Approved/denied by Commission on
ZONING APPROVED BY DATE
A,Lea c DATE 4.(cam� ``�
BUILDING DEPT APPROVED BY 'I
FIRE DEPT APPROVED BY 4 X----..-..4.lr b A. DATE 4 (oLtio-
.
CITY CLERK APPROVED BY DATE
T nevi R„oinPce T Tee• 4E—,.,( Last Business Name: e-4 /A—