TOWN OF MELBOURNE BEACH, FLORIDA REGULATION PERMIT APPLICATION FOR COMMERCIAL PHYSICAL CONTACT ESTABLISHMENTS, ADULT BOOKSTORES, ADULT DANCING FACILITIES, AND ADULT MOTION PICTURE THEATERS
Check One:
Initial Application
Renewal Application
Date
(PLEASE USE BACK AND EXTRA SHEETS PROVIDED, IF NECESSARY)
l. Application fee must be submitted with this application.
Initial application $250.00
Renewal application $100.00
2. State the name, address and date of birth of applicant or if applicant is a partnership, the names, addresses and dates of birth of the persons who constitute such partnership, or if applicant is a corporation, the names, addresses and dates of birth of its directors and officers.
3. State the current or intended address of the business for which this application has been made.
4. State the names, addresses, positions and dates of birth of all employees or persons under contract for employment or persons otherwise intended to be employed, at the business for which this application is made.
5. State the names, addresses, positions and dates of birth of all persons presently employed as independent contractors, or under contract for employment as independent contractors, at the business for which this application is made.
6. State whether the Applicant, or any person named in questions four or five (4 or 5) above, has been convicted within five years of the date of this application of any felony, or soliciting for prostitution, pandering, prostitution, keeping a house of ill fame, lewd or lascivious behavior or sale or possession of a controlled substance or narcotic.
7. If the answer to question six (6) above was yes on any count, state the name of any such person or persons convicted, the date and place of conviction, and the nature of the crime for which any such person was convicted.
No application shall be complete until all persons named in this application have been fingerprinted in the presence of a Police Officer employed by Melbourne Beach, Florida on a form approved by the Police Department and said fingerprints have been attached hereto; and the applicant has submitted two current color head to shoulders photographs.
I HEREBY SWEAR that the answers to the above are true and correct, that I have read and understand Chapter 61 of the Code of Ordinances of the Town of Melbourne Beach, Florida, entitled "Community Standards," and that I am under a continuing obligation to update the information contained in this Application.
Applicant
Position:
SWORN TO AND SUBSCRIBED BEFORE
ME THIS DAY OF
NOTARY PUBLIC
MY COMMISSION EXPIRES: