983 ATLANTIC BLVD #116 - LOCAL BUS TAX APPLICATION CITY OF ATLANTIC BEACH is°
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233 II Ito
LOCAL BUSINESS TAX APPLICATION
•
Section 1 'New APPLICATION FOR Business OTransfer Ownership OTransfer New Location:Previous
location
BUSINESS NAME ?)I1 I�'S /n _ LA-c- ( D�A f( 4 Vila
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LO CATION ADDRESS "10.5 �I c
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MAILING ADDRESS k Q t Lei o na v 0\t S 5` A 1 tel I D I Z 1 TC -a h 1 P i.�
BUSINESS PHONE CA 0-A- 2 U5- 1 -Li FAX CELL °I(�U - 3$Z'05�IL(
EMAIL ADDRESS IT VI( 1'IUIC SCI I Cfl 0 9 nC i II _ Conn
NATURE OF THE BUSINESS(Please Be Specific) COS YrC 10 l U y `n— r ��'I I r S4 In
01 not ✓tt7II
SQUARE FOOTAGE OF BUSINESS PREMISES 3002) S 'F-A"
(Include both buildings and outside areas used in conjunction with the btsiness,but not patron parking areas)
NUMBER&TYPE OF VENDING MACHINES(if any) I R
************ ****k*****>k*****#************ *0.,k#+!*********************%#*********************>#********
Section
APPLIC ANT/LOCAL MANAGER/PRINCIPAL OFFICER 12J Y 1
a �C it l e(
HO ADDRESS `u a U Vno N \\A ?jJa i_. UIY,\\, IL �
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1,451+4E
PHONE ()IDA- aJgi-411151C-4 SS#or Fed Employer ID# ,U511 0 L L4
DATE OF BIRTH \\\3\ ¶U DRIVER'S LICENSE# \-- L-kui(5J'' s2 "IO (Attach copy)
STATE LICENSE/CERTIFICATION/REGISTRATION#(if applicable,attach copy) VI C\—\2 \03
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Section 3
T,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
complia ith all provis'ons of the Code of Ordinances pertaining to conducting a business in the City of Atlantic Beach.
Signs • Title
5 tcA) te Date.2...1,2_, I 1 S
PRINT NAME
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) Zoning/Building Fee Paid on Business Tax Receipt#
❑FULL YR ❑HALF YR Business Tax Amount $ Code#&Classification
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❑ 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 ( 'i-
'�` DATE �t- °1 c-,
FIRE DEPT APPROVED BY
s�( DATE 4 (v q t%yi
CITY CLERK APPROVED BY DATE
Last Business Use: e-, Last Business Name: v-k A