983 ATLANTIC BLVD #117 - LOCAL BUSINESS TAX APPLICATION OLG1A— a3b,
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 I 1 r( C' 127ead4
BUSINESS NAME: [ M3 &O'tO t
LOCATION ADDRESS: Cl D Atlantic GI )Hc' c 1CAc )17://77.
1L/ 7
MAILING ADDRESS: 0 0 Moire al k Dr it 1-�3 -te ed r f- 3.z.9R L
BUSINESS PHONE: kD U • U-bb OFAX: CELL:
EMAIL ADDRESS: NIS(A\0 n)01 rnim-tmLy mal\ • CO at
BUSINESS ENTITY IDENTIFICATION NUMBER: Federal Employer I.D.Number
or 303 • 33 • C)° °3
Social Security Number
PLEASE EXPLAIN THE NATURE OF THE BUSINESS:
Bar 3(40►1 Re1%■15°4,5
SQUARE FOOTAGE OF BUSINESS PREMISES: 1�V
(Include both buildings and outside areas used in conjunction with the business, but not patron parking areas.)
Will the following be served? Food: Yes
Alcohol: Yes _AK If yes, Select One: 1COP 2COP 4COP
If restaurant,will dogs be allowed? Yes j>do
Will you have any vending machines? Yes 14 If yes, please provide quantity and type below:
*****************************************************************************************************
Section 2 MIN �1 p �C41
APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER:
HOME ADDRESS: —}DO NArd 4VtAlk .fir A r23 , poote tj ecirO - 3 2.0w w z
n
HOME PHONE: CELL: "tV1-1' — 149b - conq
DATE OF BIRTH: �Z{10 1 11114 DRIVERS LICENSE#: Tb2-O !"1 11.4' 0�� V (Please attach a copy.)
EMAIL ADDRESS: VS0.t0nil VIA;11\yir&L\J C f V01* i1 CDr1n ce,ci ew,
STATE LICENSE/CERTIFICATION/REGISTRATION#(if applicable,attach copy): CA. O`7 Gqi?
*****************************************************************************************************
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 compliance with all provisions of the Code of Ordinances pertaining to conducting a business in the
City of Atlantic Beach. �f } v
PRINT NAME: M.i 1 C I TITLE: ow e r / 1 ��IY SI 11S1--
SIGNATURE WW1 Tr DATE e)1 7/'7 l )/Q I
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.