899 ATLANTIC BLVD - LOCAL BUSINESS TAX APPLICATION CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233
LOCAL BUSINESS TAX APPLICATION Mt (\pu) lh2pSC!
Section 1 I O
APPLICATION FOR 131 New Business ❑Transfer Ownership ❑Transfer New Location: Previous location
BUSINESS NAME Panera Bread#1781
LOCATION ADDRESS 899 Atlantic Blvd.,Atlantic Beach,FL 32233
MAILING ADDRESS 3630 S. Geyer Rd.,Suite 100,Saint Louis,MO 63127
BUSINESS PHONE 314-984-1000 FAX 314-984-1115 CELL
EMAIL ADDRESS valerie.chin @panerabread.com/mandi.johnston@)panerabread.com
NATURE OF THE BUSINESS(Please Be Specific) Restaurant/Rakery-Cafe
SQUARE FOOTAGE OF BUSINESS PREMISES 4,125
(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/a
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Section 2
APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER Pan eirot_
HOME ADDRESS /2)(03() S_ G- 'i r 1 . ,5t, .. (lb
HOME PHONE 31 ti - ao SS#or Fed Employer ID# Dy-3a1 a 8?-8
DATE OF BIRTH KV - DRIVER'S LICENSE# f V/A (Attach copy)
STATE LICENSE/CERTIFICATION/REGISTRATION#(if applicable,attach copy) ,5'E A 2201 y99te
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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
complian with all provisions of the Code of Ordinances pertaining to conducting a business in the City of Atlantic Beach.
Signat re Title
Valerie A. Chin l 0/aSydaly
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. ❑ State Reg/Cert/Lic# ❑Health Cert#
OTHER Requires Commission Approval (_]Yes ❑No Approved/denied by Commission on
ZONING APPROVED BY DATE
BUILDING DEPT APPROVED BY "-- 1. .A 6-r-- DATE 4 1v 4 ( c
FIRE DEPT APPROVED BY .J� C.•gr—cl.l DATE 4 `O
CITY CLERK APPROVED BY DATE
Last Business Use: (\17/1 Last Business Name: /4A