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City of Pompano Beach
Department of Development Services
License Year _____________
100 W. Atlantic Blvd Pompano Beach, FL 33060 Community Residence &
Phone: 954.786.4668 Fax: 954.786.4666 Recovery Community Application
Lyingormisrepresentationinthisapplicationcanleadtorevocation.(155.8402.B.RevocationofApproval)
G:\Zoning 2009\Forms and documents\Website Documents\Word Documents\BTR\Applications\PDF\communityresidence-recovery_permit.doc
Modified: 3.21.2019 Page 1 of 5
PROCEDURE:
Submit this completed application to the Business Tax Receipt Office or send the completed application to the
Business Tax Receipt Division to the attention of the Chief BTR Inspector. Staff will process the application, and
it will be routed to a planner for review.
APPLICATION CHECKLIST: The following documentation shall be submitted with this completed application:
Submittal Requirement Contact
□
A copy of the state license with the State of
Florida to operate the proposed community
residence
(when applicable)
State of Florida Department of Health
Address: 4052 Bald Cypress Way
Tallahassee, FL 32399
Phone: 850-245-4277
Website: http://www.floridahealth.gov/
□
A copy of the Oxford House’s “Conditional
Charter Certificate” or “Permanent Charter
Certificate”
(when applicable)
Oxford House, Inc.
Address: 1010 Wayne Avenue, Suite 300
Silver Spring, MD 20910
Phone: (800) 689-6411
Website: http://www.oxfordhouse.org/userfiles/file/index.php
□
A copy of the provisional certification to
operate the proposed community
residence or recovery community
(when applicable)
Florida Association of Recovery Residences
Address: 326 W Lantana Rd., Suite 1
Lantana, FL 33462
Phone: (561) 299-0405
Website: http://farronline.org/
□
A copy of the certification or license to
operate the proposed community
residence or recovery community
(when applicable)
Florida Association of Recovery Residences
Address: 326 W Lantana Rd., Suite 1
Lantana, FL 33462
Phone: (561) 299-0405
Website: http://farronline.org/
□
A copy of the certification or license to
operate the proposed assisted living facility
(when applicable)
Agency for Health Care Administration
Address: 2727 Mahan Drive MS #30
Tallahassee, FL 32308
Phone: (850) 412-4304
Website: http://ahca.myflorida.com/
□
A copy of the standard rental/lease agreement to be used when contracting with occupants.
□
Detailed exterior site plan identifying property lines, parking spaces, storage area of garbage
receptacles, screening of garbage receptacles, fences, and other similar accessory features.
□
Detailed interior floor plan identifying all bedrooms (with dimensions excluding closets), exits and
location of fire extinguishers. (fill in the information required on the table on page 4 of this application)
□
A letter of authorization that is notarized by the property owner or corporate officer (if the property is
owned by a partnership, corporation, trust, etc. or the application is being submitted on behalf of the
owner by an authorized representative.)
□
A copy of the development order, approving a Special Exception, for the proposed use (if applicable).
□
A copy of the order, approving Reasonable Accommodations, for the proposed use (if applicable).

City of Pompano Beach
Department of Development Services
License Year _____________
100 W. Atlantic Blvd Pompano Beach, FL 33060 Community Residence &
Phone: 954.786.4668 Fax: 954.786.4666 Recovery Community Application
Lyingormisrepresentationinthisapplicationcanleadtorevocation.(155.8402.B.RevocationofApproval)
G:\Zoning 2009\Forms and documents\Website Documents\Word Documents\BTR\Applications\PDF\communityresidence-recovery_permit.doc
Modified: 3.21.2019 Page 2 of 5
Family (City Ordinance / Zoning Code / Chapter 155 Article 9 Part 5)
An individual or two or more persons related by blood, marriage, state-approved foster home placement, or
court-approved adoption—or up to three unrelated persons—that constitute a single housekeeping unit. A
family does not include any society, nursing home, club, boarding or lodging house, dormitory, fraternity, or
sorority.
Family Community Residence (City Ordinance / Zoning Code / §155.4202. H.)
A family community residence is a community residence that provides a relatively permanent living
arrangement for people with disabilities where, in practice and under its rules, charter, or other governing
document, does not limit how long a resident may live there. The intent is for residents to live in a family
community residence on a long-term basis, typically a year or longer. Oxford House is an example of a
family community residence.
Transitional Community Residence (City Ordinance / Zoning Code / §155.4202. I.)
A transitional community residence community residence is a community residence that provides a
temporary living arrangement for four to ten unrelated people with disabilities with a limit on length of
tenancy less than a year that is measured in weeks or months as determined either in practice or by the
rules, charter, or other governing document of the community residence. A community residence for people
engaged in detoxification is an example of a very short-term transitional community residence.
Recovery Community (City Ordinance / Zoning Code / §155.4203. B.)
A recovery community consists of multiple dwelling units in a single multi-family structure that are not held
out to the general public for rent or occupancy, that provides a drug-free and alcohol-free living
arrangement for people in recovery from drug and/or alcohol addiction, which, taken together, do not
emulate a single biological family and are under the auspices of a single entity or group of related entities.
Recovery communities include land uses for which the operator is eligible to apply for certification from the
State of Florida. When located in a multiple-family structure, a recovery community shall be treated as a
multiple family structure under building and fire codes applicable in Pompano Beach.
Licensing and Certification
□
Family
Community
Residence
□
Transitional
Community
Residence
□
Recovery
Community
□
Assisted
Living
Facility
□
Other:
.
__________________
□
Agency has issued a certification, provisional certificate
or license to operate the community residence as a:
□
FARR Certification Level (if applicable)
□
Name of State Licensing or Certification Agency:
□
Statutory number under which license is required:
Describe the general nature of the resident’s disabilities (developmental disabilities, recovery from addiction,
mental illness, physical disability, frail elderly, etc.) Do not discuss specific individuals:
City of Pompano Beach
Department of Development Services
License Year _____________
100 W. Atlantic Blvd Pompano Beach, FL 33060 Community Residence &
Phone: 954.786.4668 Fax: 954.786.4666 Recovery Community Application
Lyingormisrepresentationinthisapplicationcanleadtorevocation.(155.8402.B.RevocationofApproval)
G:\Zoning 2009\Forms and documents\Website Documents\Word Documents\BTR\Applications\PDF\communityresidence-recovery_permit.doc
Modified: 3.21.2019 Page 3 of 5
STREET ADDRESS (of the Subject Property):
FOLIO #:
# of Live-in Staff
Maximum # of Residents
(Licensed)
Minimum Duration of Residency Maximum Duration of Residency
Day(s) Month(s) Year(s) No Minimum Day(s) Month(s) Year(s) No Maximum
□
□
# of Bedrooms # of Dwelling Units
Will the residents be able to
maintain a motor vehicle?
No
□ Yes □If “Yes,” how many?
# of Parking Spaces On-Site
# of Parking Spaces Off-Site
(if applicable)
Has a certification been applied for and a provisional certification
been issued?
No
□
Yes
□
Special Exception #
(if applicable)
Date Provisional certification was
issued (if applicable):
Property Owner
(Please Print)
Applicant / Agent Information
(Complete if the applicant / agent is not the
owner of the property)
Business Name (if applicable): Business Name (if applicable):
Print Name and Title: Print Name and Title:
Mailing Street Address: Mailing Street Address:
Mailing Address City/ State/ Zip: Mailing Address City/ State/ Zip:
Primary Phone Number: Primary Phone Number:
Secondary/ Cell Phone Number: Secondary/ Cell Phone Number:
Email: Email:
City of Pompano Beach
Department of Development Services
License Year _____________
100 W. Atlantic Blvd Pompano Beach, FL 33060 Community Residence &
Phone: 954.786.4668 Fax: 954.786.4666 Recovery Community Application
Lyingormisrepresentationinthisapplicationcanleadtorevocation.(155.8402.B.RevocationofApproval)
G:\Zoning 2009\Forms and documents\Website Documents\Word Documents\BTR\Applications\PDF\communityresidence-recovery_permit.doc
Modified: 3.21.2019 Page 4 of 5
Number of Occupants:
Bedroom
Dimensions of each
bedroom (excluding
closets) in feet:
Total Square feet in
bedroom (excluding
closets)
Number of residents
(including any live-in
staff) to sleep in each
bedroom
Total gross floor
area of all
habitable rooms
Width
(ft)
X
Length
(ft)
Area (ft
2
)
1
If you’re unsure
how to measure
this, ask City staff
for instructions.
Print the total
gross floor area in
the cell below:
2
3
4
5
6
7
8
Totals
Residents
Square feet
Please return this completed application to:
Development Services Department
100 West Atlantic Boulevard Room 352
Pompano Beach, FL 33060
Questions? Need assistance?
Call city staff at (954) 786-4679
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City of Pompano Beach
Department of Development Services
License Year _____________
100 W. Atlantic Blvd Pompano Beach, FL 33060 Community Residence &
Phone: 954.786.4668 Fax: 954.786.4666 Recovery Community Application
Lyingormisrepresentationinthisapplicationcanleadtorevocation.(155.8402.B.RevocationofApproval)
G:\Zoning 2009\Forms and documents\Website Documents\Word Documents\BTR\Applications\PDF\communityresidence-recovery_permit.doc
Modified: 3.21.2019 Page 5 of 5
Local 24 Hour Contact Affidavit
In accordance with the responsibilities of a 24-hour contact person as provided for in § 153.33(F), the
responsibilities of the 24-hour contact person include:
Be available and have the authority to address or coordinate problems associated with the property 24 hours a
day, 7 days a week;
Monitor the entire property and ensure that it is maintained free of garbage and refuse; provided however, this
provision shall not prohibit the storage of garbage and litter in authorized receptacles for collection;
See that provisions of this section are complied with and promptly address any violations of this section or any
violations of law, which may come to the attention of the 24-hour contact person and
Inform all occupants prior to occupancy of the property regulations regarding parking, garbage and refuse, and
noise.
I certify that I have read and understand the information contained on this affidavit, and that to the best of my
knowledge such information is true, complete, and accurate.
BEFORE ME, the undersigned authority, personally appeared _________________________ (PRINT NAME)
Who after being duly sworn, deposes and says: That I am the person whose signature appears below, and
that the information I have provided above in this document is true and correct.
24 Hour Contact Property Owner Responsible Party Other (below)
Business Name (if applicable): Print Name:
Relationship to Property Owner (if applicable): Title:
Physical Street Address of Home or Business: Address City/ State/ Zip:
Primary Phone Number: Secondary/ Cell Phone Number:
Signature: Date:
SWORN TO AND SUBSCRIBED before me this _____ day of __________________________ 20_____, in
Pompano Beach, Broward County, Florida.
Notary Public ____________________________________________
Seal of Office
Notary Public, State of Florida
____________________________________________
(Print Name of Notary Public)
_________________________
Personally Known
_________________________ Produced Identification
Type of identification Produced:
____________________________________________
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Completed 14 July 2020

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