HomeMy WebLinkAboutMassage Establishment - Southside Massage RetreatINTER -OFFICE MEMORANDUM
BOARD OF PUBLIC WORKS
/ DATE SENT:
TO: ,/Federico Rodriguez, Fire Department
SCharles Bulot, Building Commissioner
�Ayoka Paek, Building Dept.
,James Burns, Police Department
Eugene Eyser, Police Department
2/17/2017
FROM: Linda M. Martin, Clerk
SUBJECT: RENEWAL- MASSA ESTABLISHMENT LICENSE
RECOMMENDATION
LOCATION: Southside Massage Retreat
DATE DUE: 02/21/2017
FAX OR E-MAIL TO: 235-9171 / ImartinC&_southbend in.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: 574.235,9 1
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LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT $-a D5'vb
MUNICIPAL CODE SECTION - 4-35
I. APPLICATION TYPE Check One: New Renewal
II. BUSINESS DATA
A. Business Name:
B. Business Addret
City: itb\ \!5VA,A)
C. Mailing Address (If different from above):
State: . 1 �� Zip:
City: State: Zip:
D. Business Telephone Number:
E. Business Fax Number: _
F. E-Mail Address: my'pkz (A a �1 - C' cwy)
G. Zoning of Business Location: \ 4?Q w_'C6
H. Have you ever had a Massage Establishment license, or similar license, suspended or revoked
by any governing municipality within three (3) years prior to the date of this application:
YES NO X
1. If yes, what was the reason:
2. If yes, what was the business occupation following the suspension/revocation:
I. Describe the nature and scope of the business:
For Office Use Only
G)oRKs
Application Filed FEB 15 2017 Public sefewyApproval
Application Fee Paid FEB 15 2017 License Fee Paid FEB 15 20174 Sent to Dept. FEB 15 2017 License Number 174d
APP$OVW
Board of Pullldc Work_,
NotApproved
Reason
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:574.23s.9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-3S
III, OWNERSHIP
A. Type of owner lip (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:
I Address:
City:
2. Partnership (List at least two (2) partners)
Name #1:
Residential Address:
City:
Name #2:
Residential Address:
City:
3. Corporation
State: a Zip:
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:
Zip:
Zip:
Business Address:
City: State: Zip:
Residential Address:
City: State: Zip:
Name #2
Title:
Business Address:
City:
Residential Address:
City:
State:
State:
FE
Zip:
2
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 - 574.23S.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:
State:
State:
IV. PERSONAL DATA
A. Applicant's Legal Name:
B. Residential Address:
City: �\ ��'� State:,_,
C. Residential Telephone Number:
D. Residential Fax Number:
E. Cellphone Num
F. E-Mail Address:
G. Position with bt
H. Please list all criminal convictions (if any), excluding traffic violations:
Nature of Conviction City State
Zip:
Date
(Attach additional sheets if necessary)
I. Please list all addresses for three (3) years prior to application date:
Street Address City State Dates
G�
(Attach additional sheets if necessary)
J. Date of
K. Gender
L. Social S
M. Race: W)(�I\`sc
3
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)
all previous employment forth ree (3) years prior -to the date of this a
Company Address City, State, ZIP Dates
I
(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, Section4-35.
Signa or Date
M