BUSINESS TAX RECEIPT CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233
LOCAL BUSINESS TAX APPLICATION
Section I
APPLICATION TYPE: New Business Transfer of Ownership ll
Transfer to New Location:Previous Location-t-�7 ff+- �'VC.Aun NOA Jl4���n�
BUSINESS NAME: 1 LU J� A VA s5,vh - I�w`Qsowv'l t.�e
LOCATION ADDRESS: �J D' I�Pvry' �„�1, A�(���1G v,pcw� L 3ac-33
MAILING ADDRESS: tC115 At L,-L(� ANA 4 303 &,,,L f=t- M-33
BUSINESS PHONE:�U`�-, IT�1bI FAX:
EMAIL ADDRESS:
BUSINESS ENTITY IDENTIFICATION NUMBER: Federal Employer I.D.Number
or
Social Security Number
PLEASE EXPLAIN THE NATURE tOF THE BUSINESS:
U.% ,r p 4l 1q'40-5 Q Y Gl y^i 'Z J)C k1
SQUARE FOOTAGE OF BUSINESS PREMISES: !� S • '�
(Include both buildings and outside areas used in conjunction with the'business,but not patron parking areas.)
Will the following be served? Food: Yes No
Alcohol: Yes If yes, Select One: 1 COP 2COP 4COP
If restaurant,will dogs be allowed? Yes 4o
Will you have any vending machines? Yes If yes, please provide quantity and type below:
Section 2
APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER:
HOME ADDRESS: MAL � c� a� � u,�v,� -L as L( �
HOME PHONE: CELL: Jug !� i q — 2-233
DATE OF BIRTH: DRIVERS LICENSE#:—693&--7 7 3 - /ZD (Please attach a copy.)
EMAIL ADDRESS: l kg-t- �� 6—D 0Ge.,5.-\ ( 1 7 /-,.^
STATE LICENSE/CERTIFICATION/REGISTRATION#(if applicable,attach copy):
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.
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PRINT NAME: �jt�G��'C TITLE: VAS Gam=
�v�9 r _ �a.
SIGNATURE 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/B ness Tax Re e' t. Ap li atipn and/or payment does not constitute approval or issuance of
a receipt.�.J v 117, //•t Z,v.� ,-�,
v� - k - -I;N -.o 4( vp ,ocv .4 t, I A (06(15�