Application For Certificate Of Registration Food And Beverage Tax Form - County Of Henrico, Virginia Department Of Finance

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County of Henrico, Virginia
Application for Certificate of Registration
Food and Beverage Tax
Department of Finance
ACCOUNT NUMBER
Business Section
PO BOX 90775
Henrico VA 23273-0775
Separate Application Required for Each Location
OWNER'S
NAME
Corporation Name or First Name, Middle Initial, and Last Name
TRADE
NAME
MAILING
ADDRESS
Number/Street or Route/Apt/Room
CITY
STATE/ZIP
LOCATION
ADDRESS
Number/Street or Route/Apt/Room
TYPE OF ESTABLISHMENT
OTHER INFORMATION
(Please √ box which is most appropriate.)
Type of Food
You Sell
01
Bakery
Average Cost of Meal for Two (including beverages and dessert) √ Applicable Response
02
Caterer
Under $25
$25-$50
$50+
03
Coffee Shop
Days and Hours of Operation
04
Convenience Store
05
Fast Food Restaurant
Seating Capacity
Square Footage
06
Full Service Restaurant
07
Gas Station
ABC License Number (if applicable)
08
Grocery Store
VA Sales and Use Number
09
Hospital or Nursing Home
Seasonal Business - Check months you are active. ( √ )
10
Industrial Cafeteria
(Complete if you are only open part of the year)
11
Mobile Food Service
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
12
Night Club or Tavern
13
Office or Government Cafeteria
Office Use Only
14
Private or Public Club
15
School, College, or University
16
Snack Bar or Concession Stand
99
Other (Please describe)
Please provide contact data for a person who has knowledge of your food and beverage tax return information and has
permission to discuss that information.
Name
Phone Number
Title
Fax Number
Location of Records
E-Mail
DECLARATION OF TAXPAYER - I declare that the foregoing and figures are true, full, and correct to the best of my knowledge and belief.
Signature/Title
Date
Name
(Please Print)
For Assistance, please call (804) 501-7354 or (804) 501-7329
REV 2/14

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