PDF Form

Application Type*

New BusinessBusiness TransferUpdateRenewal

Contact Person Name

First NameLast Name

Title

Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code

Email*

example@example.com

Phone Number*

Area CodePhone Number

Name of Business*

(Fictitious name issued under the fictitious name statute of the State of Florida)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Nature of Business*

Social Security Number (SSN) or Employer Identification Number (EIN)*

(required by Chapter 205, Florida Statutes)

If applicable to Business, please fill in the appropriate space(s) below with the number of each item described.


Entertainment: number of vendors
Carnivals, Circus or the like: number of days
Motion Picture: number of screens
Sightseeing Vehicle: number of vehicles
Amusement Park: number of rides, events, etc.
Coin Operated Machines: number of machines
ATM: number of machines
Peddling Vehicle: number of vehicles
Restaurant/Bar: occupancy of establishment
Commercial Rental: number of rental units
Apartment/Home Rental: number of rental units
Rental Units: number of units
Total number of commercial use only vehicles
Campground/RV Park/Mobile
Gas Station: number of pumps
Home Park: number of rental spaces
Automotive Repair: number of repair bays
Parking Lot: number of rental spaces
Flea Market: number of vendor spaces
Grocery Store: gross square footage
Barber/Beauty Shop: number of chairs
plus # of non-employee licensed operators
Non-Profit Events: number of vendors
Storage/Warehouse: number of rental units
Hotel/Motel: number of rental units
Propane Sales: Yes No Deli: Yes No

If applicable, please provide the following documents:

• Fictitious name registration issued by the Division of Corporations of Department of State

• Articles of Incorporation

• Certificate of Liability Insurance

• Workers Compensation Insurance or exemption

• Name, address and phone number of all corporate entities, limited liability companies, partnerships, sole proprietors, owners, partners, and managing members not listed above having an ownership interest in the business.

• State License (see reverse for required licenses that must be provided).

The applicant shall furnish all other information requested by the community development director as deemed necessary for its determination of the appropriate business tax receipt and the amount of said business tax applicable thereto.

STATEMENT: This information is given freely and voluntarily, and all the information contained in this application is true and correct.

Print Name*

Title*

Date*

Do not write below this line

-------------------------------------------------

Date Application Received	Total Tax	License Number
Category	Total Penalty Due	Zoning Compliance
Date BTR Issued	Date Paid/Receipt #	Date of Inspection (if required)
Restrictions or Comments

Additional Submittal Requirements

• Professions regulated by the Department of Business and Professional Regulation, the Florida Supreme Court, or any other state regulatory agency - submit an active state certificate, registration, or license, or proof of issuance of same. • Pharmacy – submit a current permit issued by the Board of Pharmacy. A local business tax receipt is not required in order to practice the profession of pharmacy.

• Pest control business regulated by F.S. ch. 482 - submit proof of issuance of a license from the Department Of Agriculture And Consumer Services.

• Assisted Living Facility pursuant to F.S. ch. 429 - submit proof of issuance of a license from the Agency For Health Care Administration.

• Health studio pursuant to F.S. §§ 501.012 through 501.019 or a ballroom dance studio pursuant to F.S. § 501.143 – submit a current license, registration, or letter of exemption from the Department Of Agriculture And Consumer Services. • Seller of travel pursuant to part XI of F.S. ch. 559 - submit a current registration or letter of exemption from the Department Of Agriculture And Consumer Services.

• Telemarketing business under F.S. §§ 501.604 and 501.608 - submit a current license or registration from the Department Of Agriculture And Consumer Services or a current affidavit of exemption.

• Mover or moving broker under F.S. ch. 507 - submit a current registration from the Department Of Agriculture And Consumer Services.

• Residential rental properties must obtain a Rental Registration from the City of Fellsmere prior to the issuance of a Business Tax Receipt.

• Amusement or game machine, or a coin operated or token operated vending machine that dispenses products, merchandise, or services, must secure a business tax receipt for the machines pursuant to F.S. § 205.0537, as amended. The business tax for these machines shall be assessed based on the highest number of machines located on the business premises on any single day during the previous receipted year, or if a new business, be based on an estimate for the current year.

• Transfer of an existing local business tax receipt - submit a copy of the applicant's current fictitious name registration issued by the state division of corporations or a written statement signed by the applicant setting forth the reason that the applicant need not comply with the Fictitious Name Act.

• Change of use for the property to be occupied or such property has been unoccupied for one year or more shall first be inspected by the Fire Official prior to the issuance of a Business Tax Receipt.

Application for Business Tax Receipt