HomeMy WebLinkAboutMassage Establishment - Chinese Massage SpaINTER -OFFICE MEMORANDUM
BOARD OF PUBLIC WORKS
DATE SENT:
TO: Federico Rodriguez, Fire Department
,Charles Bulot, Building Commissioner
Ayoka Paek, Building Dept.
�(James Burns, Police Department
FROM: Linda M. Martin, Clerk
SUBJECT: RENEWAL - MASSA E ESTABLISHMENT
RECOMMENDATION
LOCATION: Chinese Massage Spa
DATE DUE: 03/07/17
FAX OR E-MAIL TO: 235-9171 / Imartin(a)southbendin.gov
RECOMMENDATIONS AND COMMENTS:
By Date
2/22/2017
LICENSE
For all municipal business license questions, contact: City of South Bend • Department of Community Investment U96 ov
227 WestJefferson Blvd • Suite 1400S -South Bend, Indiana 46601 • 574.235.5912 • F: 574.235,5021 Mv. 000
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
L APPLICATION TYPE Check One: New Renewal
II. BUSINESS DATA
A. Business Name:
B. Business Address:
City: �ioa444 U4* State: rC /1Z Zip:.V) 1�'lY—
C. Mailing Address (If different from above):-4& a�yp,
City: State: Zip:
D. Business Telephone Number: �=�
C72Y 2—
E. Business Fax Number:
F. E-Mail Address:
G. Zoning of Business Locatic
H. Have you ever had a Massage Establishment license, or similar license, suspended or revoked
by any governing municip ity within three (3) years prior to the date of this application:
YES NO
1. If yes, what was the reason:
2. If yes, what was the business occupation following the suspension/revocation:
I. Describe the nature and scope of the business: prfiVI-1 � /�C/� lqe /
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For Office Use Only
Application Filed FE13' 1 LUl/ PublicSa"Ap
Application Fee PaicFEB 2 1 2017 License ee ai
Sent to Dept. FEB 21 2017 License Number
Not Approved
Reason
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For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S -South Bend, Indiana 46601 • 574.235,5912 • F: 574.235.9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
Ill. OWNERSHIP
A. Type of ownership (check one):
Sole Proprietorship. (If sole proprietorship, proceed to 1).
Partnership (If partnership, proceed to 2),
Corporation (If corporation, proceed to 3).
1. Sole Proprietor
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Name:J,+!j%d
Residential Address:?,/
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City: t�
State: 1781/— Zip:
2. Partnership (List at least two (2) partners)
Name #1:
Residential Address:
City:
Name #2:
Residential Address:
City:
3. Corporation
State:
State:
Legal name of corporation:
Date and state of incorporation:
List officers and directors who own 15% or more of stock:
Name #1:
Title:
Business Address:
City: State:
Residential Address:
City: State:
Name #2
Title:
Business Address:
City:
Residential Address:
City:
State:
State:
2
Zip:
Zip:
Zip:
Zip:
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For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • Suite 1400 S -South Bend, Indiana 46601 • 574.235.5912 • F: 574.235,9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
IV. PERSONAL DATA (Continued)
O. Please list all previous employment forth ree (3) years priorto the date of this application:
Company Address
own'e,
(Attach additional sheets if necessary)
City, State, ZIP Dates
V. INCLUDE WITH APPLICATION:
Three (3) passport photos taken within 6 months of application.
VI. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION
VIL AFFIRMATION
I, 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 agree to cooperate with any
review conducted pursuant to the licensing procedures, including permission to enter and
inspect the place of business and facilities in conjunction with such review. I have read and
understand the regulations of the Massage Establishment and/or Therapist license found in the
City of South Bend Municipal Code, Section 4-35.
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Signature
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Date
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