HomeMy WebLinkAboutTransient Merchant License Renewal - Shipshewana on the RoadJan 11 2017 16:20:50 Via Fax -> Vonage Page 005 Of 007
For all municipal business licknsa qu F_itl0ns, cant. ct: City of south Bend • Deportment or Ommunity Investmerrc
227 West Jefferson BNd • Suite 1400 S -South Bend, Indlin4 46601 • 579,M5,5912 • F: 574.235.9021 "p-ecgo 7 A Qg
LICENSE APPLICATION FOR— TRANSIENT MERCHANT
MUNICIPAL CODE SECTION - 4-60
I. APPLICATION TYPE Check One: New _. .__ _ �, _ Renewal X
11, BUSINESS DATA
A. Name of Event•. 5h17s ewana On The [toy- Gift. Fogd_0c draft Show _ ,-
B. Business Name;_ JDL Corporation
C. Business Address: --
City: East LeMy State: MiLip: _.. 49014
D, Mailing Address (if differs): --
City; — State: -_ Zip:
E. Business Telephone Number: 269.979,8888
F. Business Fax Number. 269979,1148
G, E•Mail Address: dicer a aaLcom _
H. Indiana State Retailer License number: No eeded
1, Proposed location where business will be conducted: Centu ,,Center South Band IA
J. Description of building or premises to be used: Convention Hall and Discovefy Bg[I_ftggsn
K. Proposed Dates of Operation: _.w,., Feb.
L. Proposed Hours of Operation: Feb. 11- -6:00 PM' Feb. 12 -10:00 AM-5:00 Piyl
M. Types of goods to be sold: i,,fts. clathinn. bass, purses furniture etc:,_,
N. Scales will be used in business transactions: Yes
No
if yes, please attach certificate from the Sealer of Weights and Measures.
O, Food will be served in ready -to -eat condition:'Yes
No H _
P. Description of nature of proposed advertising: rin_ t�Social Media, lntef
For Office Use Only
Application Filed _ JAN 12 2017 is Works Approval
Application Fee Paldr I I N 12 201 _
Sent. to Dept %TT1 2017~ M License Number J„
RPPga�
Not Approved._... of Puy]; Works
Reason__ _.—_ ._._ ,,..... .....:. . _........_.. �-----
Jan 11 2017 16:29:30 Via Fax —> Vonage Page 006 of 007
For all n01iclP01 business license questions, eontnct City of South tend + Department O Cornmunity Investment
227 West Jefferson tivd - Suite 1400 S •south fiend, Indiana 46601. 574.2.35.5912 • F: 574..235, )021
LICENSE APPLICATION FOR —TRANSIENT MERCHANT
MUNICIPAL CODE SECTION - 4-60
H. 13LJSINESS DATA (Continued)
Q. Contact person to be responsible for customer complaints and available at least sixty (EO)
days following last date of business:
Contact's Legal Name; Gregory G. Fountain ,__
Residential Address; „_, , _,,,�, 10740 Three Mile Rvad w_, _.__.._—
City: East LeL ..._ State:._.....__. MI,- Zip: , ,_490�l
Telephone Number: ___269;979.8888 .m
ill. PERSONAL DATA (Applicant)
A. Applicant's Legal Narne; Great y G Fountain _„_
B. Residential Address: 22_Castlereif,h Court _._...-___ .......
City: _ Battle Creetc-._.._- State: MI..-- _ Zip: __,49014
C. Residential Telephone Number: __-_ 734,276,8776 _..._..
D. Cellphone Number: _ _..� same m..-
E. Position with business: Vice.president _..�
F. Social Security Number; p Mjca_II Iand I will -provide
G. Cruder:
H. Date of birth: __ 12,(U68 _.
I. Race:—.... Cducasa0._ .,. _- ....
IV. PERSONAL DATA (Owner', if differs)
A. Owner's 4egal Name: _,,,,,_.,_,Same as above
B. Residential Address:.
City: ..__.._.n — — — _ State:
C, Residential' Telephone Number:,,
D, Celephone Number: _
E. position with business: _. „
F. Social Security Number: ,_,, ,,,_—
G, Gender:
11, Date of birth:, ,
I. Race:
V. PERSONAL DATA (Additional Owner, it applicable)
Zip:
A. Owner's Legal Name: Jwiie A.
B. Residential Address: 1,0740 Three Mile Road ..._ -.
r
Jan 11 2017 16:30:05 Via Fax -> Vonage Page 007 0f 007
For all municipal business license questions, contact: City of South Rend + ISegartment of C'oMalkinillY mvestmemt
2,V WestUefferscnl Blvd * Suite 1400 S -South Send, Indiana 46601 e S74.215.5912 • F: 574.2M ,9021
I..ICENSE APPLICATION FOR --TRA.NSIENT MERCHANT
MUNICIPAL CODE SECTION - 4-60
City:_ East Leroy _State:,_ _ .,MI —Zip: 49051
C. Residential Telephone Number: 264 9�9,9860 .-__ ......_.
D. Cellphone Number:
E. Position with business:___ President ......
F. Social Security Number: Please all andj wiiY i its@vr„de.
G. Gender: _F_.._
H. Date of birth: _ z f 17l46
1. Race:, ,,._,__CaucaSian
VI_ INCLUDE $5.00 PROCESSING FEE WITH APPLICATION
VII. INCLUDE NAMES, ADDRESSES, AND TELEPHONE NUMBERS OF ALL GROUP EVENT PARTICIPANTS.
Vlll. INCLUDE. A CURRENT CERTIFICATE OF LIABILITY INSURANCE WITH THE CITY OF SOUTH BEND LISTED
AS THE CERTIFICATE HOLDER.
IX. AFFIRMATION
1, hereby, certify and affirm that all of the information I Have given in this application is true and
accurate to the best of my knowledge. I further certify that I have in no way attempted to
mislead the City in this application by omitting facts known to me. I understand that the
completed application must be filed no later than thirty days kaeforce the planned event is to
begin. I have read and understand- 'e regulationx of the Transient Merchant license'found in
the City of South nd ML . ., ode, Section 4-60.
Signature
1 _
Date