G:\Zoning 2009\Forms and Sample documents\Website Documents\BTR\Affidavits\ adult_entertainment_aff Modified: 10.23.2012
City of Pompano Beach
Department of Development Services
Business Tax Receipt Division
100 W. Atlantic Blvd Pompano Beach, FL 33060
Adult Entertainment Affidavit
Phone: 954.786.4668 / 954.786.4633 Fax: 954.786.4666
State of Florida}
County of Broward}
I _____________________________________ am the ________________________________________
(Print Name) (Title)
of the Business know as __________________________________________ in the City of Pompano Beach, FL
(Business Name)
located at _________________________________________________________________________________.
(Address)
I acknowledge that the above business location is NOT zoned for adult bookstores, adult motels, nude entertainment
establishments, encounter studios/ modeling studios, OR adult domination/ submission parlors. I further
acknowledge that there will be NO SEXUALLY ORIENTED BUSINESS or other adult uses at the above
business; as may be defined in section 155.003 of the City of Pompano Beach Code of Ordinances. (SEE
ATTACHED)
Should this business be an Escort/ Dating Service, I certify this operation to be out-call only. NO on premise
dating.
Signature: ________________________________
SWORN TO AND SUBSCRIBED before me this
____ day of _______________ 20 ____, in Pompano Beach, Broward County, Florida.
_____
_______________________________
Notary Public Notary Public, State of Florida
Seal of Office
___________________________________
(Print Name of Notary Public)
_______ Personally Known
_______ Produced Identification
Type of identification produced:
___________________________________
