A $50 application fee must accompany this form
TR Control #:
Paid Date: _____________
Read instructions before making any entries on this form.
Failure to complete this form in its entirety may result in denial.
Print or type legibly using black ink.
If allotted space is insufficient for your answer, use a separate
sheet of paper, referencing your response with the question
Review all responses for accuracy and submit
application to:
City of Tampa
Land Development Coordination
1400 North Boulevard
Tampa, FL 33607 • (813) 274-3100 Option 2
1. Business Name
2. Mailing Address (include Zip Code)
3. Street Address of Business (include Zip Code)
4. Folio Number(s) of Property. (List ALL Folio Numbers for the Site; Folio Numbers can be obtained from a deed or tax receipt.)
5. Nature of Business. (Describe in detail)
6. Owner’s or President’s Name
7. Owner’s/President’s Address (Include Zip Code)
8. Owner’s/President’s Telephone Number(s)
If your location address or ownership changes, you MUST complete another application.
Zoning must be approved and another $50.00 application fee is required.
I acknowledge that I have read this application in its entirety and understand and agree that the provision of
false information herein shall constitute ground for denial of any permit issued pursuant hereto.
Oath: I the undersigned applicant do swear that the foregoing statements are true and correct.
Applicants Signature
LDC/Zoning: (813) 274-3100, Option 2
□ Approved □ Disapproved
LDC/Zoning Signature
LDC/Zoning Signature
Amount Paid:
Receipt #:
9. List any and all owners and partners. If a corporation, also list all officers and principal stockholders.
Name: Last
Social Security #
Date of Birth
10. List below all persons to be employed in the business to be regulated including managers, operations, employees, etc.
Name: Last
Social Security #
Date of Birth
11. Employment Record: Beginning with present position, attach an affidavit stating the business occupation, profession or
employment record of the past five years for all names listed in item 13 above, include (a) name of place (b) address (c) dates of
employment (to and from.)
12. Business Name(s) and Address(es): List below the name and street address of any and all businesses in the City of Tampa
presently owned or operated in the past by owners, officers, and principal stockholders in the business to be regulated.
Name of Business Address
13. Answer yes or no: Have you ever been arrested , indicted , or convicted of any violation of civil or
military law? If yes, attach an affidavit stating the full history of any criminal convictions (excluding misdemeanor traffic violations)
for all owners, partners, officers, principle stockholders, and employees.
14. Will the business to be regulated provide any entertainment wherein any person would expose or exhibit his or her sexual organs
in any public place or on the private premises of another or so near thereto as to be seen from such private premises?
□ Yes □ No
15. Will the business to be regulated sell, lend, give away, distribute, transmit, show or advertise in any manner, any obscene, lewd,
lascivious, filthy, indecent, sadistic, or masochistic book, magazine, periodical, pamphlet, newspaper, comic book, story paper
written or printed story or article, writing, paper, card, picture, drawing, photograph, motion picture film, figure image,
phonograph record, or wire or tape or other recording or any written, printed, or recorded matter of any such character which
may or may not require mechanical means to be transmitted into audio, auditory, visual or sensual, sensory representations of
such character? □ Yes □ No
16. Will the business to be regulated sell, or loan for monetary consideration to a juvenile, any picture, photograph, drawing,
sculpture, motion picture film, or similar visual representation or image of a person or portion of the human body which depicts
nudity, sexual contact, or sado masochistic abuse which is harmful to juveniles or any book, pamphlet, magazine, printed material,
however reproduced or sound recording which contains any matter enumerated of such nature or explicit and detailed verbal
descriptions or narrative accounts of sexual excitement, sexual conduct or sado masochistic abuse and which if taken as a whole is
harmful to juveniles (harmful to juveniles means that quality of any description or representation in whatever form of nudity,
sexual conduct, sexual excitement, or sado masochistic abuse when it predominately appeals to the pruient, shameful or morbid
interests of juveniles and is patently offensive to prevailing standards in the adult community as a whole with respect to what is
suitable material for juveniles and is utterly without redeeming social importance to juveniles)? □ Yes □ No
17. Will the business to be regulated offer entertainment in the form of bar room type nude dancing? □ Yes □ No
18. Will the owners, managers, or employees of the business to be regulated in connection with the conduct of said business suffer or
permit any female person while on the premises of said commercial establishment to expose to public view that area of the
human female breast at or below the areola thereof? □ Yes □ No
The Federal Privacy Act of 1974 requires us to inform you that providing us with your Social Security number is mandatory. Social
Security numbers for all persons are required in order for the Tampa Police Department to conduct the required positive identification
background checks pursuant to the requirements of Chapter 6 of the Code of Municipal Ordinances of the City of Tampa, Florida.
Additionally, this application is subject to the Florida Public Records Law 119.071 F.S. with the exception that social security
numbers will be withheld from public inspection and copying pursuant to the exemption found in 119.071(5)(5) F.S.
If any person listed desires to assert further 119.071 F. S. exemptions they must do so by contacting Land Development Coordination,
City of Tampa, Florida, 1400 N. Boulevard, Tampa, Florida 33607 (813) 274-3100 Option 2.
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