Occupational License/payroll Tax Application Form - County Of Boone & City Of Florence Page 2
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1
2Legal Name of Business or Applicant if Sole Proprietor
15. Owner(s) of Business (Attach additional list if necessary):
Name
Address
Phone Number
Title
Date of Birth
Social Security Number
16. Is this business being operated from a residence in Boone County?
Yes (Please complete the HOME OCCUPATION PERMIT APPLICATION)
No
(The questionnaire is located at
or by calling the Planning Commission at 859-334-2196)
17. Contact information for payroll/corporate tax for operation within City of Florence and/or Boone County (Manager, etc.)
Name
Address
Phone Number
Night/Emergency Number
E-mail
18. Has any person listed in Item 15 ever had an Occupational License or similar Business License denied, revoked or suspended in the City of
Florence, Boone County, or any other City or State? If “Yes” Please explain. (You may attach additional information sheet if needed)
Yes
No
19. Has any person listed in Item 15 ever been convicted of a Felony or Misdemeanor*?
Yes
No If Yes, Date: __________ Charge: ______________ Explanation: ___________________________________
*If more than one charge please attach the above information on each charge to an additional information sheet.
Remittance
A.
When conducting business in Boone County only, remit
B.
When conducting business in City of Florence (which is a
Boone County fee to:
part Boone County), remit City of Florence fee AND Boone
County fee to:
Boone County Fiscal Court
City of Florence
Occupational License Department
Finance Department
PO Box 960
8100 Ewing Boulevard
Burlington, KY 41005
Florence, KY 41042
Phone: (859) 334-2144
Fax (859)334-3914
Phone: (859) 647-5413
Fax: (859) 647-5447
Warning:
Statements made in this application are subject to verification and false or misleading statements may be cause for denial of the
license applied for or, if granted, revocation thereof upon discovery.
I hereby certify that I am duly authorized to act for the applicant and that the statements contained on this application are true and complete:
Name (Print)
Signature
Title
Date
For Official Use Only – Approvals/Denial
Boone County Planning Commission
Date:
Boone County Building Inspection:
Date:
City of Florence Fire Department:
Date:
Issuance of the License is:
Approved
Approved Conditional (Conditions Attached)
Denied (Notification to Applicant Attached)
Dated this
day of
20
Authorized By:
Page 2 of 2
(ALL QUESTIONS ON BOTH PAGES MUST BE ANSWERED)
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Parent category: Financial