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
Transfer to New Location:Previous Location
BUSINESS NAME: PA Irua Lo 'E
LOCATION ADDRESS:�7 S AUANTIP 3W &1J 9 4 W
MAILING ADDRESS: y21sr STN A (MMV1U.F BEACH. FL M50
BUSINESS PHONE: 904-X-`GyS14 FAX: �Qy-���' �45� CELL: ZQg-66x-7317
EMAIL ADDRESS: �FW.&J R @PMG -JO OM u
BUSINESS ENTITY IDENTIFICATION NUMBER: Federal Employer I.D.Number 97- I U/21
or
Social Security Number
PLEASEEXPLAINTHE NATURE OF THE BUSINESS:
FULL- aRVICE RESTAI1 AIT-
SQUARE FOOTAGE OF BUSINESS PREMISES: 000
(Include both buildings and-outside areas used in conjunction with the business,but not patron parking areas.)
Will the following be served? Food: G No
Alcohol: Ge No If yes,Select One: 1COP 2COP CO
If restaurant,will dogs be allowed? Yes
Will you have any vending machines? Yes If yes, please provide quantity and type below:
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Section 2
APPLICANT/LOCAL MANAGER/PRINCIPAL OFFICER: 2RhiAMlJx1 J. POUIE9
HOME ADDRESS: ZI �JJR14T j![F DR JACKsoKV1 LELUW
HOME PHONE: N A CELL: 7�q- (0-7 3 17
DATE OF BIRTH: 1117n $ DRIVERS LICENSE#: P6 36-070- 78-q o l-o (Please attach a copy.)
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EMAIL ADDRESS: A2.TEfi' P PMG- AAX GDM
STATE LICENSE/CERTIFICATION/REGISTRATION#(if applicable,attach copy):06 Na t/tff deb YC-1 w'iE4 PMTZ)r
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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 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.
f�'�iUC}Et�t-
PRINT NAME: TITLE: l/Vdlgff WILL Dr6N
SIGNATURE DATE 12 ts— ArpN
No person, firm or corporation shall engage in or manage any trade, business, profession, or occupation in Atlantic Beach
without first obtai ' g a Local.Bus Tax Receipt.Applicati9nd/or payment does not constitute approval or issuance of
a receipt. 2 1 240,1 " I