60 OCEAN BLVD - LOCAL BUS TAX APPLICATION CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233
LOCAL BUSINESS TAX APPLICATION
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Section 1
APPLICATION FOR t New Business [Transfer Ownership ❑Transfer New Location:Previous location
BUSINESS NAME ?tA
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LOCATION ADDRESS to v � �" L`� `� " ,T 'G I S 14c{-3 3
MAILING ADDRESS l c
BUSINESS PHONE el 0 4-- 37 2- (.6 - FAX CELL 76 -a(—L
EMAIL ADDRESS 1,:„.ods.e. �2 4 k 5--(k ?- r Nc-" eOM
NA MOF THE BU SS(Please Be Specific) 4—F#lt_ ST/k T F I NVz?s- -t
�-s { z;Pf-2t 14 tr µ-r
SQUARE FOOTAGE OF BUSINESS PREMISES b O 54-
(Include both buildings and outside areas used in conjunction with the business,but not patron parking areas)
NUMBER&TYPE OF VENDING MACHINES(if any) — U
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Section 2 L ��c1 ,J �QQ, I� sZ_
APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER
HOME ADDRESS 3 Z�' l S- S# r/�\
HOME PHONE 24 9 lb SS#or Fed Employer ID# 7
DATE OF BIRTH y (s S / DRIVER'S LICENSE#'pocc.) 5'\ 5-C.) (Attach copy)
STATE LICENSE/CERTIFICATION/REGISTRATION#(if applicable,attach copy) (Q 1 O Lt x233
********** *************************************************************tom** l0 OvDty '
Section 3 V
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.
Signature- Title
tSN
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
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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 7J DATE 4 l t 6 (i
FIRE DEPT APPROVED BY t _i • t.'� `{ DATE 4- r 6
CITY CLERK APPROVED BY DATE
Last Business Use: Last Business Name: