469 ATLANTIC BLVD #1 - LOCAL BUS TAX APPLICATION CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233
LOCAL BUSINESS TAX APPLICATION
Section 1 /
APPLICATION FOR [id'New Business ❑Transfer Ownership ❑Transfer New Location:Previous location
BUSINESS NAME 1 I_ N 1%C N 11_C i 1�ti
LOCATION ADDRESS_ 24 q T D S I E
MAILING ADDRESS
BUSINESS PHONE(ci C>1 > 53 6 2 1-f c FAX CELL 0/ I.0 333 9 o
EMAIL ADDRESS h i e n n g ay eAn q,,/0 5 °� y°` �" ' . C-cx.An_
NATURE OF THE BUSINESS(Please Be Specific) /v aA.-/ sit- /o 11
SQUARE FOOTAGE OF BUSINESS PREMISES /0 00
(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
T>k*****#***a:M.k***x:c*** ****$:<sc***************>t*:****;e****#>.:***********************#*****#**>t****>***
Section 2 � �\k ��u�/j��(/
APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER �� � 3 a a,D6
HOME ADDRESS / 7 g J �i4 W r h 6 �ve At-
HOME PHONE 3�� 9Q�v SS#or Fed Employer ID# 8 4 ( rid6 O
DATE OF BIRTH 02- -go_ a DRIVER'S LICENSE# 4/42 cZ 338 CO 6 - D (Attach copy)
STATE LICENSE/CERTIFICATION/REGISTRATION#(if applicable,attach copy)
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Section 3
1,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
compl'ance with all provisions of the Code of Ordinances pertaining to conducting a business in the City of Atlantic Beach.
• r Title
44A ��/2 7( Date
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) $100.00-Zoning/Building Fee Paid on Business Tax Receipt#
OFULL 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 ll-- DATE
BUILDING DEPT APPROVED BY `Ti >� c—�-� L'r—b DATE - _
FIRE DEPT APPROVED BY .�.1 -+ GrieS S DATE
CITY CLERK APPROVED BY DATE
Last Business Use: Last Business Name: