HomeMy WebLinkAboutMassage Establishment - Therapeutic Indulgence LLCINTER -OFFICE MEMORANDUM
BOARD OF PUBLIC WORKS
/ DATE SENT: 2/22/2017
TO: Federico Rodriguez, Fire Department
4�J harles Bulot, Building Commissioner
Ayoka Paek, Building Dept.
,v-4ames Burns, Police Department
FROM: Linda M. Martin, Clerk �
SUBJECT: RENEWAL - MASSAG ESTABLISHMENT LICENSE
RECOMMENDATION
LOCATION: Therapeutic Indulgence LLC
DATE DUE: 03/07/17
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 �1
227 West Jefferson Blvd • Suite 1400S -South Bend, Indiana 46601. 574.235,5912 • F: 574. 1.902 4(t5g�o
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION -4-35
I. APPLICATION TYPE Check One: New Renewal
II. BUSINESS DATA
A. Business Name: L L E
B. Business Address•
City:
C. Mailing Address (If different from,above):
City; II \\ State: Zip:
D. Business Telephone Number: (-SLU- J C510 _ mn\- \
E. Business Fax Number:
F. E-Mail Address: -\7\kU XV! aQA �17L11 �el�li�c �aMAdL Cam)
G. Zoning of Business Location:
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:
I. Describe the nature and scope of the business: M�I�E `b9 cam— 1 �15
QNQUZ�Y ��- AePs4�0a�t1c
1aP�ssPtc� t �.o, �c, SKI r� c N(?' ,�yocnk c-uA-t's'<I>, Xo
aoo.w
For Office Use Only
Application Filed FED 2 12017 Public pproval
Application Fee PLicense Fee Paid
Sent to Dept. FEB 2 12011 License Number, 17-7650
AVPAQVE6)
39strdl of Pukak Work"
Not Approved
Reason 10.9 14 7011
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 46501 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION - 4-35
III. OWNERSHIP
A. Type of owners p (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: SA(?_14 _�,)OS X-�P_ h"Z.it
Residential Address: R)-ks�ts 2
City: State: \ N Zip: AyD �
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:
Citv:
Residential Address:
City:
Zip:
Zip:
FE
Zip:
State: Zip:
State:
FZ.
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. 574,235.5912 - F: 574.235.9021
LICENSE APPLICATION FOR - MASSAGE ESTABLISHMENT
MUNICIPAL CODE SECTION -4-35
IV. PERSONAL DATA (Continued)
O. Please list all previous employment for three (3) years priorto the date of this application:
Company Address City, State, ZIP Dates
(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
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.
Signature Date