#1: BUSINESS INFORMATION (To be completed by applicant): **Instructions & checklist on reverse side**
Check Applicable Box: □ New Business □ Transfer of Address □ Transfer of Ownership □ Business Name Change
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Owner/Applicant Name: _________________________________________________________________________________________
Federal Employer ID #: ____________________________ **OR** Social Security #: __________________________________________
Business Address: ______________________________________City: ________________________ State: _____ ZIP: ____________
Applicant/Business Start Date at Location: ___________________ Business Phone Number: ____________________________________
Mailing Address (if different above): _____________________________City: ________________________ State: _____ ZIP: ____________
E-Mail address: ________________________________________________________________________________________________
Nature of Business: ___________________________________________ **OR** Profession: __________________________________
(Landscaper, Cleaning Service, etc.) (Doctor, Lawyer, etc.)
Maximum Number of: Employees: ___________ Machines: _____________ Rooms: ____________ Restaurant seating: ____________
Were you issued a Notice of Non-Compliance? _________ Yes _________ No
I certify, under penalty of law, that the above information is true and correct, and I understand that any false statements could result in penalties as provided by law.
Signature: ____________________________________________Title: ___________________________________________________
(Agent, Owner, Rep.)
Page 2
Sec. 17-17 of PBC Ordinance No. 72-7.
No business tax receipt shall be issued until applicable county and
state laws are complied with including, but not limited to, building,
re control and health.
www.pbctax.com
Application For Palm Beach County Local Business Tax Receipt
Revised 9-24-2020
PBCTC Form 65
□ Other ______________________________________
Existing PBC LBTR # (if applicable): __________________________________________________________________________________
Corporation/Business Name: ______________________________________________________________________________________
Fictitious/DBA/Trade Name: ______________________________________________________________________________________
#2: PLEASE NOTE: ZONING APPROVAL MUST BE COMPLETED PRIOR TO APPLICATION SUBMITTAL
Municipal/City Zoning Approval: __________________________________________________________ Title: _____________________
Additional Fees May Apply
Unincorporated Zoning Approval/Planning Zoning & Building Approval: _____________________________ Title: _____________________
PCN: __________________________________ePZB Application Number: __________________________ Date: ___________________
Control Number: ___________________________________ Resolution Number: _____________________________________________
Use pursuant to the PBC ULDC Article 4 supplementary use standards: _______________________________________________________
PZ&B - Check box if approval from department is required***
Regulator Signature required on line, when approval has been granted***
Zoning (U No.) _______________________________________ Fire Marshall ___________________________________
Compliance _________________________________________ Health Department _______________________________
Building ___________________________________________ Hotel & Restaurant _______________________________
NAICS Code _________________________________________ Prior Use of Bay/Bldg. ____________________________
Other______________________________________________
___________________________
FOR TCO OFFICE USE ONLY
LBTR#/Account #: ___________________________________ State/County License Cert #: ____________________________________
CSS / SCSS: _________________________ Date: ____________________ Field Service Approval: ______________________________
NAICS Code ________________________________________ TOTAL FEE DUE: $ _____________________ Receipt #: _______________
□
