HomeMy WebLinkAboutMassage Establishment - Hair CraftersSUBJECT:
INTER -OFFICE MEMORANDUM
BOARD OF PUBLIC WORKS
DATE SENT: 2/15/2017
Federico Rodriguez, Fire Department
harles Bulot, Building Commissioner
yoka Paek, Building Dept.
James Burns, Police Department
Eugene Eyser, Police Department
Linda M. Martin, Clerl�w-/
RENEWAL - MASSAGE ESTABLISHMENT LICENSE
RECOMMENDATION
LOCATION: Hair Crafters
DATE DUE: 02/21/2017
FAX OR E-MAIL TO: 235-9171 / Imartin(a)-southbendin.gov
RECOMMENDATIONS AND COMMENTS:
By Date
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 ,
6.1
ith
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
I. APPLICATION TYPE Check One: New Renewal k
II. BUSINESS DATA
A. Business Name: 4�atr Croc�ters
B. Business Address: 100a �Llrlcolh W0.V; _St
city: .500'1 f VEMA State: / N Zip: q'(O&o l
C. Mailing Address (If different from above):
City: . State: Zip:
D. Business Telephone Number: 5 74( a.8ff-a`AV9'
E. Business Fax Number: T-71f 0'33-8370
F.E-Mail Address: c' Alet,t.3in+e_(-Cej5Lc 0 L a [1-Ct
G. Zoning of Business Location: 1--8
H. Have you ever had a Massage Establishment license, or similar license, suspended or revoked
by any governing municipality 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:
1. Describe the nature and scope of the business: r'u t_t- S ER V fc E SA Lo IJ H A I Pear 7
HAIR COLOQ 1-H1LWITS,_MANICUR6.T PC0Ir_kR.6S; FRCiALsilIfkSSAE€
For Office Use Only
FEB 13 2017
Application Filed Public Approva
Application Fee Paid������ - License aFEB 1. 3 2017
Sent to Dept. FEB 13 2017 License Number 17— a
4'P.40 M
Not Approved Board of Public Works
Reason
1
e
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
III. OWNERSHIP
A. Type of ownership (check one):
Sole Proprietorship. (If sole proprietorship, proceed to 1).
Partnership (If partnership, proceed to 2).
'>c Corporation (If corporation, proceed to 3).
1. Sole Proprietor
Name:
Residential Address:
City: State:
2. Partnership (List at least two (2) partners)
Name #1:
Residential Address:
City:
Name #2:
Residential Address:
City:
Zip:
State: Zip:
State: Zip:
3. Corporation
Legal name of corporation: DEWIN-rE2 / NC
Date and state of incorporation: ) fi NU A P y l R9'3
List officers and directors who own 15% or more of stock:
Name#1: J-30NAi-O t--, br-WINTEk
Title: cAmE2 am P'r'esI e-,dt
Business Address:_ 1POA 1-I1ucoL-A7 6t��EttSt
city: Sou'/-h bid State: /N zip: L/660!
Residential Address:_ /013 1-1fleozw (,VAY LjeS`t
City: M150Y)mK4 State: /N Zip: LlbsgU
Name#2:_ kRfzA%ETl+ /+- /fir: WINrcl2
Title: eo- o ivAmr• alvLd V/CE - 19('es t /JEn/'t
Business Address: &4)d 47NGOL/Lt WA-Y Et15f
City: :50uy'h 6e4 State: J N Zip: r F & 6 01
Residential Address: 1d13 1-INCoLN WAY Gtrz5sr
City: M I5N414)g K 4 State: r N zip: qbS-'/w
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd • 5ulte 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)
N.Photographs:
Attach below (3) Passport photos, V'x1", taken within 6 months of tha rate of this application.
�r
I III
0. Please list all previous employment for three (3) years prior to the date of this application:
Company Address City, State, ZIP Dates
5AAIC A5 A-60V& 5/Ne.r; l9&3
(Attach additional sheets if necessary)
V. INCLUDE WITH APPLICATION:
Three (3) passport photos taken within 6 months of application.
VI. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION
VII. 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.
Signature Date
4
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
III. OWNERSHIP (Continued)
3. Corporation (Continued)
Name #3:
Title:
Business Address:
City:
Residential Address:
City:
IV. PERSONAL DATA
State:
State:
Zip:
Zip:
A. Applicant's Legal Name: 0 dJPrc 0 L 66 W1AJr6/'
B. Residential Address: !0 13 41Ncot nJ lNg y /0 CY7'
City: M 16H/RWAK-d7 State: //V Zip: 4(0 �!
C. Residential Telephone Number: 5 7y - oz S 5 =-6-7U /
D. Residential Fax Number:
E. Celephone Number:
F.E-Mail Address: e, dti'r (a sl7cgLlobal.ne%
G. Position with business: /9 to A&P_ cWvl d/ 17&t' '
H. Please list all criminal convictions (if any), excluding traffic
Nature of Conviction
(Attach additional sheets if necessary)
City State
I. Please list all addresses forthree (3) years prior to application date:
Street Address
<' A- Mom- F}- 5
A6oU� 5/A/6E /97/
(Attach additional sheets if necessary)
J. Date of birth:
K. Gender: Ma le-
L. Social Security Number:
M. Race: w lde-
City State
Date
Dates