HomeMy WebLinkAboutMassage Establishment - Rachael T Massage & Essential OilsINTER -OFFICE MEMORANDUM
BOARD OF PUBLIC WORKS
DATE SENT: 2/21/2017
TO: J Federico Rodriguez, Fire Department
Pharles Bulot, Building Commissioner
yoka Paek, Building Dept.
James Burns, Police Department
FROM: Linda M. Martin, Clerk�v✓
SUBJECT: RENEWAL - MASSA8E ESTABLISHMENT LICENSE
RECOMMENDATION
LOCATION: Rachael T Massage & Essential Oils
DATE DUE: 02/21/2017
FAX OR E-MAIL TO: 235-9171 / Imartin(ftouthbendin.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: 574.2 5.9021
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LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35 /
I. APPLICATION TYPE Check One: New Renewal �f
II. BUSINESS DATA
A. Business Name:
B. Business Address: (DIV 5. 64AYa hwUP
City: South &"A State: :1N Zip: 46611
C. Mailing Address (If different from above): (Dtb E /1X �Y't
City: SDA &VIJ State:. Z!J Zip: 'IV(Q11
D. Business Telephone Number: 04) 394-31ota4
E. Business Fax Number:
F. E-Mail Address: rq(%Igt_�iIYlA55grkC, eoilsa�amail .cnrn
G. Zoning of Business Location:
H. Have you ever had a Massage Establishment license, or similar license, suspended or revoked
by any governing municipality 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:
L Describe the nature and scope of the business: Fhoyldl� YDp rfic- rnas oge 414PAa/
For Office Use Only
Application Filed FEB 2 0 2017 /
Application Fee Paid d 0 2017
Sent to Dept. FER 2 0 2017
Not Approved
Reason
Fee Paid
APPj3>�VE�
Ooard Of Puiplip Works
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For all municipal business license questlons, 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).
Corporation (If corporation, proceed to 3).
1. Sole Proprietor
Name: fuchn<_ Ii -Thom0500 np�
Residential Address: 15y S. (':r�gwonc k
City: SO4�� btgl _ State: =Al _Zip: __
2. Partnership (List at least two (2) partners)
Name #1:
Residential Address:
City:
Name #2:
Residential Address:
City:
State: Zip:
State: Zip:
3. Corporation
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:
Citv:
Residential Address:
City:
Name #2:
Title:
Business Address:
Citv:
Residential Address:
City:
State:
Zip:
State: T Zip:
State: _ Zip:
State:
Zip:
Pa
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: V haf I-E(iZ&de :IDMu31)11
B. Residential Address: `{64 g� Ud7 SiDltt Ayt
City: South btnd State: :U) Zip: llioblq
C. Residential Telephone Number: 21W)M-*�3yq-13kN
D. Residential Fax Number:
E. Cellphone Number:(5� 3>a i —3loIL
F. E-Mail Address:
G. Position with bt
H. Please list all criminal convictions (if any), excluding traffic violations:
Nature of Conviction
City State Date
(Attach additional sheets if necessary)
1. Please list all addresses for three (3) years prior to application date:
Street Address City State
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(Attach additi—'-",.,....:F ---------t
J. Date of birtl
K. Gender:_E
L. Social Secm
M. Race: 14h
Dates
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. PERSONAI F)ATA m .-•--')
rtl
O. Please list all previous employment for three (3) years prior -to the date of this application:
Company Address
City, State, ZIP Dates
KQkt14\ chum-lir- aiyal Cluttarid lei/ Smh bend q(&a� slmlo-�_;LDI
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(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.
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Signa ure Date