363 ATLANTIC BLVD - LOCAL BUS TAX APPLICATION CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD,ATLANTIC BEACH, FL 32233
LOCAL BUSINESS TAX APPLICATION
Section 1
APPLICATION TYPE: C New Business Transfer of Ownership
Transfer to New Location: Previous Location (521/ 3'21'SfreP4- llQc-B-h x)( 8COL (L
BUSINESS NAME: k Iv(1 D t n , I ti Ci
LOCATION ADDRESS: /36 ? M tc, Blvd 5u 1 v0. -;c eeoc h F•1 -2,42:?-.
MAILING ADDRESS: "silarre, 05 COSJ.12..
.USINESS PHONE: *2L 7-5l-10 FAX: C l o g-DIA 7` L (YR CELL: OD.( e .l '1 •I 3
EMAIL ADDRESS: 1c rvl hcAp_s r\ •ka-
BUSINESS ENTITY IDENTIFICATION NUMBER: Federal Employer I.D.Number C°‘ 3 40 61 t 0 Ce b
or
Social Security Number
PLEASE EXPLAIN THE NATURE OF THE BUSINESS:
\ * -(2- Q Des \
SQUARE FOOTAGE OF BUSINESS PREMISES: L S O 0
(Include both buildings and outside areas used in conjunction with the business, ut not patron parking areas.)
Will the following be served? Food: Yes No
Alcohol: Yes ® If yes,Select One: I COP 2COP 4COP
If restaurant,will dogs be allowed? Yes No
Will you have any vending machines? Yes ® If yes, please provide quantity and type below:
*****************************************************************************************************
Section 2
APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER: �C� 6�Iee�� � �rR-GIZ�
HOME ADDRESS: 61C! Jay is Nei+- ch R 52-2•( Q
• HOME PHONE: - - q (4,3 CELL:
DATE OF BIRTH: DRIVERS LICENSE#: c5-3 - t 1-0(Please attach a copy.)
•M �EMAIL ADDRESS: tykS nrci\ (SQI.641.
STATE LICENSE/CERTIFICATI /REGISTRATION#(if applicable,attach copy):
e *****************************************************************************************************
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.
PRINT NAME: K .i1it€en 4(rips E� Z�
TITLE: ri(ale-g_,
SIGNATURE ~XA DATE -c_
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.