ABCC BTR APPROVAL CITY OF ATLANTIC BEACH c//Z
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233
LOCAL BUSINESS TAX APPLICATION
Section 1
APPLICATION FOR 9"New Business GTransfer Ownership ❑Transfer New Location:previous location_
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BUSINESS NAME ATu rrC lW �/� N 7/� - 2*
LOCATION
32*
LOCATION ADDRESS
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Sr _
MAILING ADDRESS SA-m/= 45
BUSINESS PHONE 90 4-3 77- FAX 4 ' 5— $'40 CELL
EMAIL ADDRESS �Jm� T 7/ �-- ow7 C�-U13
NATURE OF THE BUSINESS(Please Be Specific)S 1'-PARA- r G�-+' o 1'o O7k(= �� ���)
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SQUARE FOOTAGE OF BUSINESS PREMISES /D d S Sa r �'C/ 1 t
(Include both buildings and outside areas used in conjunction with the business,but not patron parking areas)
NUMBER&TYPE OF VENDING MACHINES(if any)
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Section 2
APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER � � �r � .,310
HOME ADDRESS �Z�� Dfo v
100
HOME PHONE 904-7--77.
ZL/D / SS#or Fed Employer ID# � '"3 �
DATE OF BIRTH / Z 3 !d / DRIVER'S LICENSE# 2(o "02/ o 3 ✓O (Attach copy)
STATE LICENSE/CERTIFICATION/REGISTRATION#(if applicable,attach copy)
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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 int e
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
compli ce with all provisions of the Code of Ordinances pertaining to conducting a business in the City of Atlantic Beach.
Title
Signature
i
PRINT NAME Date
~ No person,firm or corporation shall engage in or manage any trade,business,profession, or occupation in Atlantic Beach without
ee
first obtaining a:s Local
Business
Tax Receipt.Application and/or pa
d/orpa men does es no constitute
approval
ppo:gal o issuance
ssua c of r c rpt
Section 4(For Office Use Only) $100.00-Zoning/BuildingFee Paid on Business Tax Receipt
❑FULL YR ❑HALF YR Business Tax Amount $
Code#&Classification
❑ Fictitious Name Reg. ❑ Corporation Reg. ❑ State Reg/CerVLic#
❑Health Cert#
OTHER Requires Commission Approval Yes No Approved/denied by Commission on
DATE
ZONING APPROVED BY DATE
BUILDING DEPT APPROVED BY
FIRE DEPT APPROVED BY DATE
DATE
CITY CLERK APPROVED BY
Last Business Use: Last Business Name: +-c �>�--