983 ATLANTIC BLVD #116 - LOCAL BUS TAX APPLICATION (2) CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233 ! 5 - ®c CM 8/0
LOCAL BUSINESS TAX APPLICATION v,�
Section 1
APPLICATION FOR l New Business OTransfer Ownership OTransfer New Lo ation:Previous location \
BUSINESS NAME
■ • ' ' C C" ' ► ■ t.h •c Bch Ft
LOCATION ADDRESS • ■r�
MAILING ADDRESS ,,11//. _ C. � • • I.
CELL�OA �SS� � � 1
BUSINESS PHONE�l"[ ' (Qc-8c"4 W FAX
EMAIL ADDRESS " y Vf 1-A 4' e S��1v Yl 1 G 1 . C U t') •
(Please Be Specific) �� +a 1 l lO 1 lr s:3,() !l
NATURE OF THE BUSINESS(P p )r ��
∎rt-t ■
SQUARE FOOTAGE OF BUSINESS PREMISES 0 0 c
(Include both buildings and outside areas used in conjunction with the businels,but not patron parking areas)
NUMBER&TYPE OF VENDING MACHINES(if any) N 1
k*****%#*3Y**>f>k:k**********k**:<******** *Yak******skit*****tit$ek***>ffR******$:t******+k+k**k:k%k****>k*#+'*****>#ie***
Section 2
APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER_A'I ISo r) 1 ` 1 !� e K,
HOl9IEADDRESS rte/ C Ili ' . UOC . b - 4-(4,
e SS#or Fed Employer ID# 514i - �Z ZV 9 (.P
PHONE °117 #. COSS'81�4 �" _
DATE OF BIRTH (i, -ZS".FL' DRIVER'S LICENSE# K'\52-00 L -6W 1ZS (Qach copy)
STATE LICENSE/CERTIFICATION/REGISTRATION#(if applicable,attach copy) C L 1\113`D e
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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
compliance with all provisions of the Code of Ordinances pertaining to conducting a business in the City of Atlantic Beach.
M.Q.k0(11- .iSAAAda- 0 \N ne r
Signature Title
PA\k 0VI 0 i M f < 0 '2_ - Z- \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 .5400116-:
Zoning/Building Fee Paid on Business Tax Receipt#
-5-lJ.o0
❑FULL YR ❑HALF YR Business Tax Amount s Code#&Classification
El Fictitious Name Reg. ❑ Corporation Reg. 0 State Reg/Cert/Lic#
❑Health Cert#
OTHER Requires Commission Approval Yes No Approved/denied by Commission on___
ZONING APPROVED BY DATE
- 3.'-'t DATE �( I o`-
BUILDING DEPT APPROVED BY .�C'
FIRE DEPT APPROVED BY
S — DATE .4- t o l
CITY CLERK APPROVED BY DATE
Last Business Use: A(,......( Last Business Name: /