[County Ordinance 72-1 and FS 205.0535(5)]
No business tax receipt shall be issued until applicable
county and state laws are complied with including, but
not limited to, building, zoning, construction industry
licensing, fi re control and health.
www.taxcollectorpbc.com
Application For Palm Beach County Local Business Tax Receipt
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
□ New Business Tax Receipt □ Other ________________________________________________________
Current Business Tax Receipt # (if applicable): __________________________________________________________________________
Business/DBA/Trade Name: ______________________________________________________________________________________
(Division of Corporations requires registration of a fi ctitious name. Copy of registration must accompany this application)
Corporation /Business Name: _____________________________________________________________________________________
Owners Name: ________________________________________________________________________________________________
Federal Employer ID #: ____________________________ **OR** Social Security #: __________________________________________
Business Address: ______________________________________City: ________________________ State: _____ ZIP: ____________
Date in business at this 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.)
PLEASE NOTE: ZONING APPROVAL MUST BE COMPLETED PRIOR TO APPLICATION SUBMITTAL **See reverse side for details on zoning**
Municipal/City Zoning Approval: __________________________________________________________ Title: _____________________
**OR** Unincorporated Zoning Approval/
Planning Zoning & Building Approval: ______________________________________________________ Title: _____________________
PZ&B - Place initials in box if approval from department is required*** Regulator Signature required on line, when approval has been meet ***
Zoning (U No.) _______________________________________
Fire Marshall ___________________________________
Compliance _________________________________________
Health Department _______________________________
Building ___________________________________________
Hotel & Restaurant _______________________________
NAICS Code _________________________________________
Prior Use of Bay/Bldg. ____________________________
Other _____________________________________________
Cnty Home Based Affi davit __________________________
FOR TCO OFFICE USE ONLY (Signature and title designates approval)
LBTR#/Account #: _____________________________Branch Offi ce: _____________________________________ CURRENT YR
Till number: __________________________________ State/County License Cert #: __________________________ 1 YR
NAICS Code: _________________________________Receipt #: ________________________________________ 2 YR
Cust. Relations Guide/ CRA: _____________________________________________________________________ 3 YR
Date:_______________________________________ Field Service Approval: _______________________________ 4 YR
TOTAL FEE DUE : $ _____________________________________________________________________________ 5 YR
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